A practical framework for evaluating a culturally tailored adolescent substance abuse treatment programme in Molokai, Hawaii

Objective. Successful substance abuse treatment requires many changes in behavior, attitude and skills. Culturally tailored approaches to substance abuse treatment have shown initial success, but are not yet accepted as best practice models. In order to document programme effectiveness of a new culturally tailored substance abuse treatment programme on the rural island of Molokai, Hawaii, the authors worked to develop a multi-level evaluation plan to measure behavior changes occurring after participation in activities targeting identified causes of substance abuse in the population of interest.

Methods. The authors compiled interview results to develop a map of identified causes of substance abuse in the community studied. Strategic planning then identified the specific activities aimed at impacting identified root causes. A literature review was performed to document the effectiveness of such activities. An evaluation plan was developed to measure programme impact on antecedent conditions contributing to substance use in this community.

Results. Prioritized causes of substance abuse in the target group included low self esteem, lack of self identity and life plan, and limited communication and conflict resolution skills. Activities targeting these conditions included cultural activities, group counseling, and individual counseling. Literature to support the benefit of addressing these factors was uncovered, and evaluation methodology was developed to measure changes in behaviors, attitudes, and practices, as a measure of programme success.

Discussion. While programme evaluation data is still being collected, the authors have demonstrated a sound foundation for programme activities, and designed methodology for collecting meaningful data to measure programme effectiveness at changing important root causes of substance abuse in a rural Native Hawaiian community.     

Prevention of fall injuries requiring hospital treatment among community-dwelling elderly

Background: To reduce the number of fall injuries requiringhospital treatment among community-dwelling elderly a community-basedintervention programme was set up. The study was designed asa prospective intervention study with the intervention consistingof information and home visits with follow-up, removing physicalhazards, treating somatic and psychiatric illnesses and dealingwith improper drug consumption, diet insufficiencies and physicaland mental inactivity. The setting was five municipalities ofthe county of Vejle, Denmark (intervention area) with 12,905community-dwelling elderly (65 years) and four other municipalitiesin the same county (control area) with 11,460 community-dwellingelderly (65 years) from 1 January 1986 to 31 March 1988. Method:A separate injury register at hospitals, with catchment areasfor the above study population, was established to collect informationon fall-related injuries among the community dwelling elderlywho were referred to out-patient treatment or hospitalization.The fall injuries requiring treatment were registered for ninemonths prior to the intervention and for 18 months during theimplementation of the intervention programme. Results: The preventedfraction was estimated for all fractures, lower extremity fracturesand hip fractures. A non-significant reduction of 14% in thenumber of all fractures was found in the intervention groupcompared with the control group. The reduction of lower extremityfractures in the intervention group was found to be significantlygreater: 33% (95% CI: 3–63%), due to a highly significantreduction among women: 46% (95% CI: 8–84%), but withoutreduction among men. Similarly a high, although non-significant,reduction of hip fractures among women was found: 43% (95% CI:-2 - 88%). The reductions appeared to be highest in the lastnine months of the intervention period and highest among womenliving alone. Conclusion: It is possible to reduce the numberof major fall-related fractures among elderly with a well-integrated,community-based intervention programme having information, homevisits and follow-up as major components and utilizing existinghealth personnel in a municipality.     

Cost-effectiveness analysis of the national decentralization policy of antiretroviral treatment programme in Zambia

Background

In resource-limited settings with a high prevalence of human immunodeficiency virus (HIV) infection such as Zambia, decentralization of HIV/acquired immunodeficiency syndrome (HIV/AIDS) treatment and care with effective use of resources is a cornerstone of universal treatment and care.

Objectives

This research aims to analyse the cost effectiveness of the National Mobile Antiretroviral Therapy (ART) Services Programme in Zambia as a means of decentralizing ART services.

Methods

Cost-effectiveness analyses were performed using a decision analytic model and Markov model to compare the original ART programme, ‘Hospital-based ART’, with the intervention programme, Hospital-based plus ‘Mobile ART’, from the perspective of the district government health office in Zambia. The total cost of ART services, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) were examined.

Results

The mean annual per-patient costs were 1259.16 USD for the original programme and 2601.02 USD for the intervention programme, while the mean number of QALYs was 6.81 for the original and 7.27 for the intervention programme. The ICER of the intervention programme relative to the original programme was 2965.17 USD/QALY, which was much below the willingness-to-pay (WTP), or three times the GDP per capita (4224 USD), but still over the GDP per capita (1408 USD). In the sensitivity analysis, the ICER of the intervention programme did not substantially change.

Conclusion

The National Mobile ART Services Programme in Zambia could be a cost-effective approach to decentralizing ART services into rural areas in Zambia. This programme could be expanded to more districts where it has not yet been introduced to improve access to ART services and the health of people living with HIV (PLHIV) in rural areas.

     

Health care in and outside a DMP for type 2 diabetes mellitus in Germany-results of an insurance customer survey focussing on differences in general education status

Aim  The Disease Management Programmes (DMPs) introduced in Germany since 2003 are intended to improve health care for the chronically ill. Whether they do this is currently being investigated in various evaluation settings. In order to assess possible changes in the process quality from the point of view of patients, the BARMER health insurance company conducted a national postal survey in Germany in 2007 of its customers with diabetes mellitus type 2 in order to compare programme participants and non-participants. This evaluation is a sub-analysis intended to clarify whether the utilisation, acceptability and perceived benefits of the programme differ as a result of educational status. Subjects and Methods  A nationally representative random sample was drawn from BARMER insurance customers with type 2 diabetes, aged 45–79 years. Questionnaires were evaluated from 38.5% of the sample (DMP-participant respondents: n = 2,158; non-participant respondents: n = 2,182). Results  A lower educational status was related among other things with increased morbidity, a poorer level of information and also a less well-developed “preventive attitude” to the disease. The finding that 49% of participants had a higher school qualification compared with 45% of non-participants, although significant, is less pronounced than the differences found between DMP participants and non-participants for other values analysed. A social influence could be found concerning the differences in treatment provided within the programme. A multivariate analysis shows that both the participation in the programme and higher levels of education have independent positive effects on the satisfaction with health status, with the effect of programme participation being stronger. Conclusions  It can be assumed that the clear differences established between the groups of DMP participants and non-participants can in no way be explained solely by the comparatively small difference related to school education. Patients obviously appreciate the fact that the health personnel and the insurance company are paying increased interest to their disease, and this is true to an increased degree for participants with only basic schooling. Although overall this group is significantly under-represented among the participants, they reported to an increased degree that they were profiting from the programme.

Perceptions, knowledge and beliefs about prevention of cardiovascular diseases in Villa Nueva, Guatemala

Background

In Guatemala, cardiovascular diseases are becoming the leading cause of mortality and disability. The rising burden of these diseases makes it imperative to formulate effective community-based interventions. The success of these interventions will depend on the felt needs of the community. Therefore, in this study we assessed perceptions, knowledge and beliefs about cardiovascular diseases in community members, health workers and policy makers from Villa Nueva, a community selected by the Ministry of Health of Guatemala as a site to develop a cardiovascular disease prevention programme. This study provides baseline information for designing and implementing the demonstration programme.

Methods

Qualitative methods (focus group discussions and in-depth interviews) were used to elicit the views of community members, health workers, and policy makers on the magnitude, impact, risk factors and prevention of cardiovascular diseases and infrastructure in Villa Nueva.

Results

Community members perceive cardiovascular diseases as a serious health problem that has increased in recent years. They consider cardiovascular diseases to be acute dramatic events of sudden onset. According to health professionals and policy makers, the adoption of Western lifestyles by the population is the most important contributor to the increase of cardiovascular diseases in Guatemala. They indicated that prevention requires education of the population, together with adequate health policies. According to most participants, the infrastructure for the management of cardiovascular diseases at the primary health care level is inadequate.

Conclusion

Findings from this study suggest strategies for context-specific formulation of the cardiovascular prevention programme.     

Action leadership: The development of an approach to leadership enhancement for grassroots community leaders in children's mental health

The last decade has seen the development of a number of interagency systems for children with serious emotional disturbances and their families. Many public sector agencies, however, continue to have inadequate or fragmented services. It is believed that effective systems of care for children and families will not be adequate until more parents and community residents are involved in all phases of systems development. Consequently, the need for the development of leadership models that enhance the involvement of grassroots community leaders is crucial. This article summarizes a research team's preliminary experience in developing an action leadership model that empowers grassroots community leaders toward action. The team discovered that leadership enhancement and development of grassroots community leaders is not a static skill attribute of an individual but rather is acquired through a dynamic process in which both the facilitator of a community leadership initiative and its natural leaders are active participants in a shared learning and change experience.     

Promoting exercise on prescription: recruitment, motivation, barriers and adherence in a Danish community intervention study to reduce type 2 diabetes, dyslipidemia and hypertension

Objective  The aim of this study is to analyse recruitment, motivation, barriers and adherence to increasing physical activity in a community-based 1-year intervention. Research design and methods  This study included a baseline investigation of 1,156 participants (67% female, 33% male), a post-intervention investigation after 4 months and a follow-up assessment after 1 year. All patients included in the study were physically inactive, had a body mass index (BMI) of less than 35 and were mobile enough to participate in physical training. The inclusion criteria are at least one of the following diagnoses: type 2 diabetes, above-normal cholesterol level (dyslipidemia) or above-normal blood pressure (hypertension). Theory-based activities to promote physical activity and nutrition counselling were implemented, and self-report questionnaires investigated attitude, experiences and barriers towards physical activity and self-reported health. Results  The findings indicated an increase in physical activity and fitness level, weight loss and lower body mass index both immediately after the training period and after 1 year. The programme led to reduced tobacco use. The recruitment of the patients is not representative of the general population. More better educated and female patients participated in the programme. Weight loss was the main motivation for participation, while weight gain was the main reason for dropping out of the programme. Patients who lived with a partner accomplished 10% more than did patients who lived alone, and patients who reported a good or very good state of health at baseline were more successful in completing the programme than were patients who reported having a “bad” state of health. The reported psychological barriers include physical barriers, emotional barriers, motivational barriers and time-related barriers. Motivation was strengthened by the training group, and especially the overweight patients experienced coherence and meaning in the group training activities. Conclusions  A theory-driven community intervention can lead to an increase in physical activity. Training with a group is beneficial for motivation and adherence.

Needs, education and accreditation in occupational medicine in Italy

In Europe, continuing medical education is one of the main instruments for improving physicians performance and ensuring adequate health care for citizens. Recent regulations have made such continuing education compulsory in Italy. Considering the particular features of occupational medicine, the Italian Society of Industrial Medicine and Industrial Hygiene (S.I.M.L.I.I.) recently set up a specific education and accreditation programme for occupational physicians, called the Excellence Accreditation Scheme. The programme is based on the findings of a survey among occupational physicians, carried out in collaboration with the National Institute of Occupational Safety and Prevention (I.S.P.E.S.L.), which enquired into their training and continuing education needs. The programme started in 2003, and its first edition—presented here—involved more than 400 physicians specialising in occupational health.     

How valuable are environmental health interventions? Evaluation of water and sanitation programmes in India

Objective

To evaluate and quantify the economic benefits attributable to improvements in water supply and sanitation in rural India.

Methods

We combined propensity-score “pre-matching” and rich pre–post panel data on 9500 households in 242 villages located in four geographically different districts to estimate the economic benefits of a large-scale community demand-driven water supply programme in Maharashtra, India. We calculated coping costs and cost of illness by adding across several elements of coping and illness and then estimated causal impacts using a difference-in-difference strategy on the pre-matched sample. The pre–post design allowed us to use a difference-in-difference estimator to measure “treatment effect” by comparing treatment and control villages during both periods. We compared average household costs with respect to out-of-pocket medical expenses, patients'' lost income, caregiving costs, time spent on collecting water, time spent on sanitation, and water treatment costs due to filtration, boiling, chemical use and storage.

Findings

Three years after programme initiation, the number of households using piped water and private pit latrines had increased by 10% on average, but no changes in hygiene-related behaviour had occurred. The behavioural changes observed suggest that the average household in a programme community could save as much as 7 United States dollars per month (or 5% of monthly household cash expenditures) in coping costs, but would not reduce illness costs. Poorer, socially marginalized households benefited more, in alignment with programme objectives.

Conclusion

Given the renewed interest in water, sanitation and hygiene outcomes, evaluating the economic benefits of environmental interventions by means of causal research is important for understanding the true value of such interventions.     

Cost-effectiveness of a hypertension management programme in an elderly population: a Markov model

Background

Mounting evidence shows that multi-intervention programmes for hypertension treatment are more effective than an isolated pharmacological strategy. Full economic evaluations of hypertension management programmes are scarce and contain methodological limitations. The aim of the study was to evaluate if a hypertension management programme for elderly patients is cost-effective compared to usual care from the perspective of a third-party payer.

Methods

We built a cost-effectiveness model using published evidence of effectiveness of a comprehensive hypertension programme vs. usual care for patients 65 years or older at a community hospital in Buenos Aires, Argentina. We explored incremental cost-effectiveness between groups. The model used a life-time framework adopting a third-party payer's perspective. Incremental cost-effectiveness ratio (ICER) was calculated in International Dollars per life-year gained. We performed a probabilistic sensitivity analysis (PSA) to explore variable uncertainty.

Results

The ICER for the base-case of the "Hypertension Programme" versus the "Usual care" approach was 1,124 International Dollars per life-year gained. PSA did not significantly influence results. The programme had a probability of 43% of being dominant (more effective and less costly) and, overall, 95% chance of being cost-effective.

Discussion

Results showed that "Hypertension Programme" had high probabilities of being cost-effective under a wide range of scenarios. This is the first sound cost-effectiveness study to assess a comprehensive hypertension programme versus usual care. This study measures hard outcomes and explores robustness through a probabilistic sensitivity analysis.

Conclusions

The comprehensive hypertension programme had high probabilities of being cost-effective versus usual care. This study supports the idea that similar programmes could be the preferred strategy in countries and within health care systems where hypertension treatment for elderly patients is a standard practice.     

Human resource development and antiretroviral treatment in Free State province, South Africa

Background

In common with other developing countries, South Africa's public health system is characterised by human resource shortfalls. These are likely to be exacerbated by the escalating demand for HIV care and a large-scale antiretroviral therapy (ART) programme. Focusing on professional nurses, the main front-line providers of primary health care in South Africa, we studied patterns of planning, recruitment, training and task allocation associated with an expanding ART programme in the districts of one province, the Free State.

Methods

Data collection included an audit of professional nurse posts created and filled following the introduction of the ART programme, repeated surveys of facilities providing ART over two years to assess the deployment of staff, and secondary data analysis of government personnel databases to track broader patterns of recruitment and training.

Results

Although a substantial number of new professional nurse posts were established for the ART programme in the Free State, nearly 80% of these posts were filled by nurses transferring from other programmes within the same facility or from facilities within the same district, rather than by new recruits. From the beginning, ART nurse posts tended to be graded at a senior level, and later, in an effort to recruit professional nurses for the ART programme, the majority (54.6%) of nurses entering the programme were promoted to a senior level. The vacancy rate of nurse ART posts was significantly lower than that of other posts in the primary health care (PHC) system (15.7% vs 37.1%). Nursing posts in urban ART facilities were more easily filled than those in rural areas, exacerbating existing imbalances. The shift of nurses into the ART programme was partially compensated for by the appointment of additional support staff, task shifting to community health workers, and a large investment in training of PHC workers. However, the use of less-trained, mid-level enrolled nurses and nursing assistants in the ART programme remained low.

Conclusion

The introduction of the ART programme has revealed both strengths and weaknesses of human resource development in one province of South Africa. Without concerted efforts to increase the supply of key health professionals, accompanied by changes in the deployment of health workers, the core goals of the ART programme – i.e. providing universal access to ART and strengthening the health system – will not be achieved.     

Developing a community facilitator‐led participatory learning and action women's group intervention to improve infant feeding,care and dental hygiene practices in South Asian infants: NEON programme

IntroductionThe Nurture Early for Optimal Nutrition (NEON) study is a multiphase project that aims to optimize feeding, care and dental hygiene practices in South Asian children <2 years in East London, United Kingdom. The multiphase project uses a participatory learning and action (PLA) approach facilitated by a multilingual community facilitator. In this paper, we elaborate on the process and results of the Intervention Development Phase in the context of the wider NEON programme.MethodsQualitative community‐based participatory intervention codevelopment and adaptation.SettingCommunity centres in East London and online (Zoom) meetings and workshops.ParticipantsIn total, 32 participants registered to participate in the Intervention Development Phase. Four Intervention Development workshops were held, attended by 25, 17, 20 and 20 participants, respectively.ResultsCollaboratively, a culturally sensitive NEON intervention package was developed consisting of (1) PLA group facilitator manual, (2) picture cards detailing recommended and nonrecommended feeding, care and dental hygiene practices with facilitators/barriers to uptake as well as solutions to address these, (3) healthy infant cultural recipes, (4) participatory Community Asset Maps and (5) list of resources and services supporting infant feeding, care and dental hygiene practices.ConclusionThe Intervention Development Phase of the NEON programme demonstrates the value of a collaborative approach between researchers, community facilitators and the target population when developing public health interventions. We recommend that interventions to promote infant feeding, care and dental hygiene practices should be codeveloped with communities. Recognizing and taking into account both social and cultural norms may be of particular value for infants from ethnically diverse communities to develop interventions that are both effective in and accepted by these communities.Patient and Public Involvement and EngagementConsiderable efforts were placed on Patient/Participant and Public Involvement and Engagement. Five community facilitators were identified, each of which represented one ethnic/language group: (i) Bangladeshi/Bengali and Sylheti, (ii) Pakistani/Urdu, (iii) Indian/Gujrati, (iv) Indian/Punjabi and (v) Sri Lankan/Tamil. The community facilitators were engaged in every step of the study, from the initial drafting of the protocol and study design to the Intervention Development and refinement of the NEON toolkit, as well as the publication and dissemination of the study findings. More specifically, their role in the Intervention Development Phase of the NEON programme was to:

• 1.Support the development of the study protocol, information sheets and ethics application.
• 2.Ensure any documents intended for community members are clear, appropriate and sensitively worded.
• 3.Develop strategies to troubleshoot any logistical challenges of project delivery, for example, recruitment shortfalls.
• 4.Contribute to the writing of academic papers, in particular reviewing and revising drafts.
• 5.Develop plain language summaries and assist in dissemination activities, for example, updates on relevant websites.
• 6.Contribute to the development of the NEON intervention toolkit and recruitment of the community members.
• 7.Attend and contribute to Intervention Development workshops, ensuring the participant''s voices were the focus of the discussion and workshop outcomes.

     

Public preferences for government spending in Canada

Introduction

Tuberculosis remains a major public health problem in India with the country accounting for one-fifth or 21% of all tuberculosis cases reported globally. The purpose of the study was to obtain an understanding on pro-poor initiatives within the framework of tuberculosis control programme in India and to identify mechanisms to improve the uptake and access to TB services among the poor.

Methodology

A national level workshop was held with participation from all relevant stakeholder groups. This study conducted during the stakeholder workshop adopted participatory research methods. The data was elicited through consultative and collegiate processes. The research study also factored information from primary and secondary sources that included literature review examining poverty headcount ratios and below poverty line population in the country; and quasi-profiling assessments to identify poor, backward and tribal districts as defined by the TB programme in India.

Results

Results revealed that current pro-poor initiatives in TB control included collaboration with private providers and engaging community to improve access among the poor to TB diagnostic and treatment services. The participants identified gaps in existing pro-poor strategies that related to implementation of advocacy, communication and social mobilisation; decentralisation of DOT; and incentives for the poor through the available schemes for public-private partnerships and provided key recommendations for action. Synergies between TB control programme and centrally sponsored social welfare schemes and state specific social welfare programmes aimed at benefitting the poor were unclear.

Conclusion

Further in-depth analysis and systems/policy/operations research exploring pro-poor initiatives, in particular examining service delivery synergies between existing poverty alleviation schemes and TB control programme is essential. The understanding, reflection and knowledge of the key stakeholders during this participatory workshop provides recommendations for action, further planning and research on pro-poor TB centric interventions in the country.     

Effectiveness of a nationwide interdisciplinary preventive programme for latex allergy

Objectives: The increasing prevalence of latex allergy among healthcare workers is a large socio-economical problem for the society and affected individuals. The objective of this study was to describe and evaluate a nationwide, interdisciplinary campaign by the institution for the German workers compensation scheme for non-public healthcare providers that targeted the reduction of exposure to powdered high-protein latex gloves. Methods: The effectiveness of the prevention programme is described and evaluated with a before-and-after design comparing data on compensation claims for latex-related skin and airway diseases of the German statutory compensation scheme for work-related diseases in non-public health services. A survey on change in glove use was conducted after the programme. Results: The main feature of the campaign among healthcare workers (budget €340,000) was to increase awareness by means of educational components on the aetiology of latex hypersensitivity for healthcare workers and their providers, and professional trainers. The number of reported compensation claims for latex-induced skin diseases increased from a pre-measure of 664 in 1996 to 884 during the programme in 1998 and decreased after the programme (post-measure n=567 in 1999 and n=204 in 2002). Doctors assistants in practices and nurses/nurse assistants/midwives filed most claims. Similar decreases were observed for confirmed claims and latex-related respiratory diseases, while two other prevalent occupational diseases in healthcare workers (low-back disorders, infections) increased during this time period. The survey demonstrated a considerable concurrent drop in the use of powdered latex gloves (hospitals 76% vs 37% for unsterile gloves and 86% vs 62% for sterile gloves). Conclusions: The campaign against latex allergy in connection with concurrent corresponding recommendations, activities of State authorities for worker protection, and regulations, is an example for the successful incorporation of research results into preventive measures that directly affect the frequency of a work-related disease. This effective programme can be regarded as a model for the reduction of other occupational diseases such as bakers or isocyanate asthma.     

Food Composition Activities in the English-speaking Caribbean (CARICOMFOODS)

The focus of food composition activities in the English-speaking Caribbean is the establishment of CARICOMFOODS as the regional data center. This project will be of particular value in the areas of nutrition research and education, food consumption studies and product development, food trade and food and agricultural policy development and guidelines. The data center will be housed at the Caribbean Food and Nutrition Institute, a PAHO Regional Center in Jamaica and managed by a Regional Food Composition Steering Committee.Two major limitations characterize current food composition data in the English-speaking Caribbean:

• •the incompleteness of nutrient profiles of foods especially with regards to lipids, minerals and dietary fibre,
• •a discernible absence of nutrient data on a number of foods commonly consumed by peoples of the Caribbean as well as data on composite dishes prepared by traditional cooking procedures.

To address the limitations, the Caribbean Food and Nutrition Institute (CFNI) has embarked on a structured regional programme to create an up-to-date nutrient database of foods consumed. The planned five-year development programme aims at compiling nutrient information in a computerized database (CARICOMFOODS) in a form which facilitates regional and international access and interchange. The regional programme includes

• •identification of commonly consumed single foods and prepared dishes;
• •chemical analyses of selected foods/dishes;
• •collation of compositional data drawn from published and unpublished sources;
• •calculation of nutrient content of cultural recipes; and
• •establishment of Caribbean Food Images Library.

     

A Group-Based Training Programme for General Practitioners: A Norwegian Experience

Westin S, stensen A I, Lvslett K, Prytz J, Telje J, TelstadW and Lie A. A group-based training programme for general practitioners:a Norwegian experience. Family Practice 1988; 5: 244–252. There are approximately 3000 general practitioners in Norway,serving a population of slightly above four million people.A three year postgraduate education scheme for general practitionershas been in effect since 1973, to be replaced by a five yearvocational training programme from January 1985, making generalpractice a fully recognized specialty from that date. The educationalrequirements consist of one year of hospital training, fouryears of training in general practice, and a total of 400 hoursof course education, mainly in clinical subjects. The core elementof the training is attendance at a group-based structured educationalprogramme of two years' duration. This article describes theconcepts and content of this decentralized group-based education,as well as some of the conflicting considerations which eventuallyled to this new Norwegian model of general practice training.The first evaluation studies indicate that the educational programmehas met a long standing need among general practitioners.     

Prevention of non-communicable diseases: Risk factors in youth: The North Karelia Youth Project (1984-88)

The North Karelia Youth Project is based on the results of previouspilot studies in North Karelia and forms part of the North Kareliaintegrated programme for non-communicable diseases prevention,co-ordinated by the WHO and conducted by the Finnish NationalPublic Health Institute. The project is designed to test thefeasibility and effects of a largescale health programme among12–16 year old schoolchildren. The educational programmeaims to prevent cigarette smoking and alcohol use mainly bytraining pupils to resist social pressures and by modifyingperceived social norms which may lead to smoking and alcoholuse. The dietary intervention aims to improve dietary habitsto decrease serum cholesterol and blood pressure level. Theprogramme also aims to promote positive decision-making andcoping skills and to increase social support for coping withstress. The study, which began in the autumn of 1984 provides a comprehensivethree-year programme for all seventh graders (ages 12–13)and succeeding age cohorts in North Karelia (24 schools) andin selected schools in the county of Kuopio (eight schools),including approximately 4 000 students in the first year and12 000 over the entire study period. Simultaneously successivemeasurements are implemented in all the intervention schoolsand in eight randomized reference schools, which will allowus to evaluate the programme and to test a number of hypothesesabout programme effects. The preventive programme is designedto make the best possible use of existing resources (teachers,parents, community) and will require only relatively modestnew expenditure so that, if proved effective, it can be continuedon a permanent basis. A baseline survey of the schools was carried out in the springof 1984 among ninth-graders. Twenty-four per cent of the boysand 18% of the girls reported smoking daily and 13% and 9% respectivelywere occasional smokers. About 20% had used alcohol during thepast week, 7% reported "passing out" because of drinking duringthe last year and 12% had been deeply drunk. The mean serumcholestrol level was 4.7 mmol/l and the mean blood pressure130/66 mmHg. At this baseline survey, the levels of these variableswere generally comparable in the different randomly assignedstudy groups, although there was a trend towards less smokingand alcohol use at baseline in the schools in North Kareliathan in those in the county of Kuopio.     

The effects of oral clefts on hospital use throughout the lifespan

Background

Task-shifting to lay community health providers is increasingly suggested as a potential strategy to overcome the barriers to sustainable antiretroviral treatment (ART) scale-up in high-HIV-prevalence, resource-limited settings. The dearth of systematic scientific evidence on the contributory role and function of these forms of community mobilisation has rendered a formal evaluation of the published results of existing community support programmes a research priority.

Methods

We reviewed the relevant published work for the period from November 2003 to December 2011 in accordance with the guidelines for a synthetic review. ISI Web of Knowledge, Science Direct, BioMed Central, OVID Medline, PubMed, Social Services Abstracts, and Sociological Abstracts and a number of relevant websites were searched.

Results

The reviewed literature reported an unambiguous positive impact of community support on a wide range of aspects, including access, coverage, adherence, virological and immunological outcomes, patient retention and survival. Looking at the mechanisms through which community support can impact ART programmes, the review indicates that community support initiatives are a promising strategy to address five often cited challenges to ART scale-up, namely (1) the lack of integration of ART services into the general health system; (2) the growing need for comprehensive care, (3) patient empowerment, (4) and defaulter tracing; and (5) the crippling shortage in human resources for health. The literature indicates that by linking HIV/AIDS-care to other primary health care programmes, by providing psychosocial care in addition to the technical-medical care from nurses and doctors, by empowering patients towards self-management and by tracing defaulters, well-organised community support initiatives are a vital part of any sustainable public-sector ART programme.

Conclusions

The review demonstrates that community support initiatives are a potentially effective strategy to address the growing shortage of health workers, and to broaden care to accommodate the needs associated with chronic HIV/AIDS. The existing evidence suggests that community support programmes, although not necessarily cheap or easy, remain a good investment to improve coverage of communities with much needed health services, such as ART. For this reason, health policy makers, managers, and providers must acknowledge and strengthen the role of community support in the fight against HIV/AIDS.     

The training and development needs of midwives in Indonesia: paper 2 of 3

Background

There is a shortfall in midwives in Indonesia (an estimated 26 per 100 000 people), which means that the quality of antenatal, perinatal and postnatal care varies widely. One consequence of this is the high rate of maternal and perinatal mortality, which has prompted a number of health initiatives. The current study was part of a review of the existing complex system of midwifery training and the development of a coherent programme of continuing professional development, tighter accreditation regulations and clearer professional roles. Its aims were to identify the occupational profiles and development needs of the participating midwives, and to establish whether any differences existed between grades, geographical location and hospital/community midwives.

Methods

A psychometrically valid training-needs instrument was administered to 332 midwives from three provinces, covering both hospital and community staff and a range of midwifery grades. The instrument had the capacity to identify occupational roles and education/training needs of the respondents.

Results

The occupational roles of the midwives varied significantly by province, indicating regional service delivery distinctions, but very little difference in the roles of hospital and community midwives. The most educated midwives attributed more importance to 35 out of the 40 tasks, suggesting an implicit role distinction in terms of level of activity. All midwives reported significant training needs for all 40 tasks. The most-educated midwives recorded training needs for 24 tasks, while the less-educated had training requirements for all tasks, which suggests that new training programmes are effective. Few differences in training needs were revealed between hospital and community midwives

Conclusion

The results from this survey suggest important regional differences in how the midwife's role is discharged and underline the importance of this sort of research, in order to ensure the suitability of basic and postbasic educational provision. The study also highlights the need for further development and training of midwives in a wide range of tasks. These results provide a systematic and reliable overview of current midwifery roles and development needs and could serve to inform future training.     

Is home delivery really preferred? a mixed-methods national study in Pakistan

Background

Pakistan has a high maternal mortality ratio and a low rate of skilled birth attendants (SBAs). To address these two important issues, the Pakistan Maternal Newborn and Child Health (MNCH) programme launched the community midwives (CMW) initiative in 2007. CMWs are supposed to conduct deliveries at community level outside health facilities. The purpose of the current study is to document perceptions about CMWs and preferences for birthing place.

Methods

A mixed-methods study was conducted covering four provinces. For the quantitative survey, households were selected through a multistage sampling technique from rural districts. In 1,450 rural households, preferences of respondents about CMW-conducted deliveries were recorded. Qualitative data were obtained through focus group discussions (FGDs) and in-depth interviews (IDIs) with women, community elders, CMWs, and MNCH programme personnel in the same areas where the quantitative study was carried out. In both studies, preferences and the reasons behind particular respondent preferences were recorded. Frequencies of responses were analysed for the quantitative study. Narration and quotes from various types of participants were used to present findings from FGDs and IDIs.

Results

In the quantitative study, 42% of respondents expressed a preference for birthing stations, i.e. a place where CMWs conduct deliveries; 22% preferred home deliveries. Birthing stations were favoured because of the availability of space and equipment and the proximity to women’s homes. These findings were largely supported by the qualitative component, although a range of views about where a CMW should conduct deliveries were expressed.

Conclusion

Insights into where CMWs might provide delivery services were obtained through this study. Birthing stations may be an option as a preferred location for delivery care and should be considered as part of Pakistan’s national CMW programme.