Training health visiting support staff to detect likelihood of possible postnatal depression

Community nursery nurses (CNNs) and health visiting assistants (HVAs) are increasingly working and supporting health visitors (HVs) within clinical settings. The acute shortage of HVs and increased workloads has resulted in routine services normally provided by HVs, such as detection/screening for postnatal depression, no longer being offered. A training programme for CNNs and HVAs in the use of detector questions in assisting the possible detection of women at risk of PND was completed by eight CNNs and eight HVAs. Twelve trainees consolidated the taught sessions involving specific learning outcomes and satisfactory completion of a designated competency framework within the clinical setting at the six-to-eight-week child health review in 15 GP practices. HVs provided mentorship and assessment within this clinical environment. The evaluation suggests that trainees valued the training, and with supervision CNNs and HVAs become comfortable in providing this additional service within health visiting teams.     

Screening for postnatal depression: not a simple task

OBJECTIVE: To evaluate an established screening program for postnatal depression using the Edinburgh Postnatal Depression Scale (EPDS) in a rural Victorian shire. By protocol, all women were screened at three time points post delivery by maternal and child health nurses. The efficacy of this approach in detecting probable depression was examined and referral pathways analysed. METHODS: Records for a 12-month cohort of women giving birth in the shire were audited (n = 267). Information collected included EPDS scores, parity, mother's age, reasons for non-completion, referral details and nurses' comments. Analysis was completed using database and SPSS programs. RESULTS: The process goal of screening on all three occasions was rarely achieved--a goal met for only 15.5% of women; 22% were never screened at all. The highest rate of screening was 50.6% at one month, falling to 38.1% at eight months. Reasons for non-screening varied, suggesting no simple remedy. The proportions of women identified as probably depressed at each screening point (3.1%, 4.8% and 9.2%) were considerably lower than statewide figures for rural women. Referrals of probably depressed women were mainly to GPs but the results were unclear. CONCLUSIONS: A well-established program of universal screening was not effective in detecting probable depression in women. There was little evidence of direct feedback from GPs about women referred as a result of screening and no collaborative planning for affected women. Before universal screening of women for postnatal depression can be recommended, better evidence of its feasibility and acceptability are required, alongside convincing evidence that screening leads to improved outcomes for women.     

Cost-effectiveness of HIV counseling and testing in US prisons

The prevalence of human immunodeficiency virus (HIV) in correctional facilities is much higher than in the general population. However, HIV prevention resources are limited, making it important to evaluate different prevention programs in prison settings. Our study presents the cost-effectiveness of offering HIV counseling and testing (CT) to soon-to-be-released inmates in US prisons. A decision model was used to estimate the costs and benefits (averted HIV cases) of HIV testing and counseling compared to no CT from a societal perspective. Model parameters were HIV prevalence among otherwise untested inmates (1%); acceptance of CT (50%); risk for HIV transmission from infected individuals (7%); risk of HIV acquisition for uninfected individuals (0.3%); and reduction of risk after counseling for those infected (25%) and uninfected (20%). Marginal costs of testing and counseling per person were used (no fixed costs). If infected, the cost was $78.17; if uninfected, it was $24.63. A life-time treatment cost of $186,900 was used to estimate the benefits of prevented HIV infections. Sensitivity and threshold analysis were done to test the robustness of these parameters. Our baseline model shows that, compared to no CT, offering CT to 10,000 inmates detects 50 new or previously undiagnosed infections and averts 4 future cases of HIV at a cost of $125,000 to prison systems. However, this will save society over $550,000. Increase in HIV prevalence, risk of transmission, or effectiveness of counseling increased societal savings. As prevalence increases, focusing on HIV-infected inmates prevents additional future infections; however, when HIV prevalence is less than 5%, testing and counseling of both infected and uninfected inmates are important for HIV prevention.     

Cost-effectiveness of tuberculosis screening and observed preventive therapy for active drug injectors at a syringe-exchange program

This study examined whether costs associated with tuberculosis (TB) screening and directly observed preventive therapy (DOPT) among drug injectors attending a syringe exchange are justified by cases and costs of active TB cases prevented and examined the impact of monetary incentives to promote adherence on cost-effectiveness. We examined program costs and projected savings using observed adherence and prevalence rates and literature estimates of isoniazid (INH) preventive therapy efficacy, expected INH hepatoxicity rates, and TB treatment costs; we conducted sensitivity analyses for a range of INH effectiveness, chest X-ray (CXR) referral adherence, and different strategies regarding anergy among persons affected with human immunodeficiency virus (HIV). For 1,000 patients offered screening, incorporating real observed program adherence rates, the program would avert $179,934 in TB treatment costs, for a net savings of $123,081. Assuming a modest risk of TB among HIV-infected anergic persons, all strategies with regard to anergy were cost saving, and the strategy of not screening for anergy and not providing DOPT to HIV-infected anergic persons resulted in the greatest cost savings. If an incentive of $25 per person increased CXR adherence from the observed 31% to 50% or 100%, over a 5-year follow-up the net cost savings would increase to $170,054 and $414,856, respectively. In this model, TB screening and DOPT at a syringe exchange is a cost-effective intervention and is cost-saving compared to costs of treating active TB cases that would have occurred in the absence of the intervention. This model is useful in evaluating the cost impact of planned program refinements, which can then be tested. Monetary incentives for those referred for screening CXRs would be justified on a cost basis if they had even a modest beneficial impact on adherence.     

Policy tools for building health education and preventive counseling into managed care

CONTENT: Six policy tools for building health education and preventive counseling into managed care are presented, and the opportunities and barriers to implementing each are described based largely on managed care plans operating in California in 1998. The six policy tools include (1) covering health education and preventive counseling as defined benefits, (2) increasing access to and use of health promotion programs, (3) incorporating health education into disease-management programs, (4) defining quality performance measures for health education and preventive counseling, (5) defining performance targets and guarantees for health education and preventive counseling to hold health plans accountable for providing these services, and (6) building collaboration between public health agencies and managed care on public health education and health promotion. For each of these, the policy option is described, examples of current practice are provided, and the problems and limitations associated with each are discussed.     

Cost-effectiveness of interventions to support self-care: a systematic review

OBJECTIVES: Interventions to support patient self-care of their condition aim to improve patient health and reduce health service costs. Consequently, they have attracted considerable policy interest. There is some evidence of clinical effectiveness but less attention has been paid to whether these interventions are cost-effective. This study examines the quality and quantity of existing evidence of the cost-effectiveness. METHODS: A systematic review was carried out to assess the extent and quality of economic evaluations of self-care support interventions. Thirty-nine economic evaluations were assessed against a quality checklist developed to reflect the special features of these interventions. RESULTS: The majority of the studies claimed that self-care support interventions were cost-effective or cost saving. The overall quality of economic evaluations was poor because of flaws in study designs, especially a narrow definition of relevant costs and short follow-up periods. CONCLUSIONS: The current evidence base does not support any general conclusion that self-care support interventions are cost-effective, but ongoing trials may provide clearer evidence.     

Cost-effectiveness of nutritional counseling for obese patients and patients at risk of ischemic heart disease

OBJECTIVES: Obesity and dyslipidemia are risk factors for ischemic heart disease, and prevention and treatment in primary care can reduce these risks. The objective of this cost-effectiveness analysis was to compare the costs and effects (in terms of life years gained) of providing nutritional counseling by a general practitioner (GP) or a dietician. METHODS: A total of 60 GPs, who accepted to participate, were randomized either to give nutritional counseling or to refer patients to a dietician for counseling. The life years gained was estimated using a Cox regression model. Costs were estimated on the basis of registered use of time (dieticians) or agreed salaries (GPs). RESULTS: The effect of nutritional counseling comparing GPs and dieticians is greatest when counseling is performed by a GP--0.0919 years versus 0.0274 years. These effects appear to be moderate, but they are significant. It is also proven that the GP group was the most cost-effective-the cost of gaining 1 extra life year was estimated to be 8213 DKK compared with the dietician group, for which the incremental cost-effectiveness ratio was estimated to be 59,987 DKK. CONCLUSIONS: The effects were moderate, but other studies of other patient groups and interventions report effects within the same magnitude. The GP group was the most cost-effective, but it must be concluded that both counseling strategies were relatively cost-effective. Even though the cost of gaining an extra life year was estimated to be 59,987 DKK in the dietician group, this might be an acceptable price.     

Acceptance and experience of treatment for postnatal depression in a community mental health setting

Our objective in this qualitative study was to investigate the acceptance and experience of treatment for postnatal depression (PND). Fifteen women who had received treatment and support from the community mental health service for PND were interviewed. Interviews were transcribed verbatim and then analyzed using the modified analytic induction method. The majority of women interviewed had reached "crisis point" before they sought and received treatment. The stigma attached to an inability to cope and being a "bad mother" emerged as the main barrier to seeking help earlier. In addition, women were unable to differentiate between "normal" levels of postpartum distress and depressive symptoms that might require intervention. Talking about their distress and experiences, both with health professionals and other mothers, was regarded as of primary importance in the recovery process.     

产后抑郁症发病时对产妇配偶的情绪影响

目的探讨首发产后抑郁症患者发病时对其配偶情绪的影响。方法采用焦虑自评量表（SAS）、抑郁自评量表（SDS）对4_4例产后抑郁症患者的配偶进行调查。结果44例配偶的SDS和SAS得分分别为（36.82±6.69）分和（31.55±6.18）分,均明显高于国家常模（P〈0.01）;分析结果,抑郁和焦虑得分呈负相关。结论产后抑郁症可导致患者配偶明显的抑郁和焦虑,建议给其适当的心理辅导及支持性心理干预。     

Cost-effectiveness of counseling and pedometer use to increase physical activity in the Netherlands: a modeling study

Background

Counseling in combination with pedometer use has proven to be effective in increasing physical activity and improving health outcomes. We investigated the cost-effectiveness of this intervention targeted at one million insufficiently active adults who visit their general practitioner in the Netherlands.

Methods

We used the RIVM chronic disease model to estimate the long-term effects of increased physical activity on the future health care costs and quality adjusted life years (QALY) gained, from a health care perspective.

Results

The intervention resulted in almost 6000 people shifting to more favorable physical-activity levels, and in 5100 life years and 6100 QALYs gained, at an additional total cost of EUR 67.6 million. The incremental cost-effectiveness ratio (ICER) was EUR 13,200 per life year gained and EUR 11,100 per QALY gained. The intervention has a probability of 0.66 to be cost-effective if a QALY gained is valued at the Dutch informal threshold for cost-effectiveness of preventive intervention of EUR 20,000. A sensitivity analysis showed substantial uncertainty of ICER values.

Conclusion

Counseling in combination with pedometer use aiming to increase physical activity may be a cost-effective intervention. However, the intervention only yields relatively small health benefits in the Netherlands.     

Cost-effectiveness of free HIV voluntary counseling and testing through a community-based AIDS service organization in Northern Tanzania

OBJECTIVES: We evaluated the cost-effectiveness of fee-based and free testing strategies at an HIV voluntary counseling and testing (VCT) program integrated into a community-based AIDS service organization in Moshi, Tanzania. METHODS: We waived the usual fee schedule during a 2-week free, advertised VCT campaign; analyzed the number of clients testing per day during prefree, free, and postfree testing periods; and estimated the cost-effectiveness of limited and sustained free testing strategies. RESULTS: The number of clients testing per day increased from 4.1 during the prefree testing interval to 15.0 during the free testing campaign (P<.0001) and remained significantly increased at 7.1 (P<.0001) after resumption of the standard fees. HIV seroprevalence (16.7%) and risk behaviors were unchanged over these intervals. Modeled over 1 year, the costs per infection averted with the standard fee schedule, with a 2-week free VCT campaign, and with sustained free VCT year-round were $170, $105, and $92, respectively, and the costs per disability-adjusted life year gained were $8.72, $5.40, and $4.72, respectively. CONCLUSIONS: The provision of free VCT enhances both the number of clients testing per day and its cost-effectiveness in resource-limited settings.     

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健康咨询热线电话是健康教育人际传播方式之一,它能及时快捷地帮助求询者获取所需的健康知识,摆脱健康问题的困扰,从而保持身心健康。武汉市疾病预防控制中心自2005年1月1日起开通95120预防医学咨询热线,为公众建立了一条求询防病信息和防病知识的通道,深受百姓欢迎。为了解求询者对建康知识的需求情况,该文对三年来武汉市预防医学咨询热线电话接听信息进行分析。