The European Smoking Prevention Framework Approach (EFSA): an example of integral prevention

A smoking prevention project in six European countries (European Smoking prevention Framework Approach) was developed, featuring activities for adolescents, schools and parents, including out-of-school activities. Consensus meetings resulted in agreement between the countries on goals, objectives and theoretical methods. Countries' specific objectives were also included. National diversities required country-specific methods to realize the goals and objectives. The community intervention trial was used as the research design. Since interventions took place at the community level, communities or regions were allocated at random to the experimental or control conditions. Complete randomization was achieved in four countries. At baseline, smoking prevalence among 23 125 adolescents at the start of the project was 5.6% for regular smoking and 4.0% for daily smoking. Smoking prevalence rates were higher among girls than boys in all countries as far as weekly smoking was concerned. Process evaluations revealed that the project's ambitions were high, but were limited by various constraints including time and delays in receiving funds. Future smoking prevention projects should aim to identify the effective components within the social influence approach as well as within broader approaches and on reaching sustained effects.     

Measuring mental health in a cost-effective manner

Mental health has been found to contribute significantly to the global burden of disease. This has raised the profile of mental health in developing countries. Many countries still do not have mental health policies, nor do they incorporate mental health in their primary care package. Community mental health profiles are needed to inform policy. There is a demand for more studies of mental health and the inclusion of mental health measures in more general, comprehensive, population-based health surveys. This article reviews the use and performance of a World Health Organization-endorsed instrument known as the Self-Reporting Questionnaire 20 items (SRQ20). The paper concludes that the high face and criterion validity, ease of use and suitability for administration by lay workers support the use of the SRQ20 as a cost-effective instrument with which to measure community mental health.     

The Methodological Quality of Economic Evaluations of Guideline Implementation into Clinical Practice: A Systematic Review of Empiric Studies

OBJECTIVES: Despite the emphasis on efficiency of health-care services delivery, there is an imperfect evidence base to inform decisions about whether and how to develop and implement guidelines into clinical practice. In general, studies evaluating the economics of guideline implementation lack methodological rigor. We conducted a systematic review of empiric studies to assess advances in the economic evaluations of guideline implementation. METHODS: The Cochrane Effective Professional and Organisational Change Group specialized register and the MEDLINE database were searched for English publications between January 1998 and July 2004 that reported objective effect measures and implementation costs. We extracted data on study characteristics, quality of study design, and economic methodology. It was assessed whether the economic evaluations followed methodological guidance. RESULTS: We included 24 economic evaluations, involving 21 controlled trials and three interrupted time series designs. The studies involved varying settings, targeted professionals, targeted behaviors, clinical guidelines, and implementation strategies. Overall, it was difficult to determine the quality of study designs owing to poor reporting. In addition, most economic evaluations were methodologically flawed: studies did not follow guidelines for evaluation design, data collection, and data analysis. CONCLUSIONS: The increasing importance of the value for money of providing health care seems to be reflected by an increase in empiric economic evaluations of guideline implementation. Because of the heterogeneity and poor methodological quality of these studies, however, the resulting evidence is still of limited use in decision-making. There seems to be a need for more methodological guidance, especially in terms of data collection and data synthesis, to appropriately evaluate the economics of developing and implementing guidelines into clinical practice.     

Social capital and mental health: a comparative analysis of four low income countries

Women and the poor are disproportionately affected by common mental disorders (CMD), and women in low income countries are particularly at risk. Social capital may explain some of the geographical variation in CMD, but the association between social capital and CMD in low income countries has rarely been studied. This paper aims to explore the relationship between individual and ecological measures of social capital and maternal CMD in four low income countries. Cross-sectional data from the Young Lives (YL) study with information across 234 communities in Peru, Ethiopia, Vietnam and Andhra Pradesh (India) were used. The mental health of mothers of one-year-old children (n=6909), and the individual cognitive and structural social capital of all respondents was assessed. Ecological social capital was calculated by aggregating individual responses to the community level. Multi-level modelling was used to explore the association between individual and ecological (community level) social capital and maternal CMD in each of the four countries, adjusting for a wide range of individual and community level confounders. The analysis shows that individual cognitive social capital is associated with reduced odds of CMD across all four countries. The results for structural social capital are more mixed and culturally specific, with some aspects associated with increased odds of CMD. This suggests that structural social capital has context-specific effects and cognitive social capital more universal effects on maternal CMD.     

Understanding laboratory testing in diagnostic uncertainty: a qualitative study in general practice.

BACKGROUND: Better knowledge of the professional's motives for ordering laboratory tests in the case of diagnostic uncertainty may lead to interventions directed at reducing unnecessary testing. AIM: To gain insight into the general practitioner's (GP's) motives for ordering laboratory tests for patients presenting with unexplained complaints. DESIGN OF STUDY: Semi-structured interviews based on surgery observations. SETTING: Twenty-one general practices in rural and urban areas of The Netherlands. METHOD: Investigation of the GP's perception of determinants of test-ordering behaviour in the situation of diagnostic uncertainty. The interviews were structured by evaluating the consultations and test-ordering performance of that day. RESULTS: Dutch GPs vary considerably in their motives for ordering tests. Numerous motives emerged from the data. Some examples of important themes include: personal routines; tolerance of diagnostic uncertainty; time pressure; and tactical motives for test ordering. Complying with the perceived needs of the patient for reassurance through testing is seen as an easy, cost- and time-effective strategy. A clear hierarchy in the determinants was not found. CONCLUSION: The decision to request laboratory testing is the result of a complex interaction of considerations that are often conflicting. Designers of interventions meant to improve the ordering of tests should be aware of the numerous determinants, and take contextual variables into account.     

Two percent of HIV-positive U.S. blood donors are infected with non-subtype B strains

To estimate the prevalence of HIV strains other than the predominant HIV-1B subtype in the U.S. blood donor population we genetically and serologically characterized HIV in infected blood donations collected throughout he United States from 1997 to mid-2000. Using a combination of DNA heteroduplex mobility and DNA sequence analyses of the env and gag regions of HIV-1 we determined that 285 of 312 infections were caused by HIV-1B and six by non-subtype B HIV-1 (four HIV-1C, one HIV-1AE, one HIV-1A). Genetic distances of greater than 14% in the envelope V3-V5 region of the four HIV-1C strains indicated that they did not share a recent common origin. HIV-1 group M, N, and O, and HIV-2 specific peptide serological testing of the 20 PCR-negative samples determined that one infection was caused by HIV-2 and none by HIV-1 group N and O. The major risk factor for infection with a non-HIV-1B strain was sex with an HIV-infected person from Africa although three of seven non-HIV-1B-infected subjects did not fit that category. For four of seven non-HIV-1B-infected subjects the subtype detected was consistent with the African country of origin of the infected person or of their sexual partner. The frequency of genetically confirmed non-subtype-B HIV infection in a geographically dispersed group of infected U.S. blood donors in 1977-2000 was therefore 2.0% (6/312).     

Sulfation pharmacogenetics: SULT1A1 and SULT1A2 allele frequencies in Caucasian, Chinese and African-American subjects

Sulfotransferase (SULT) enzymes catalyze the sulfate conjugation of drugs, other xenobiotics, neurotransmitters and hormones. The genes for SULT1A1 and SULT1A2 contain common genetic polymorphisms that are associated with individual variations in levels of enzyme activity as well as variations in biochemical and physical properties. We set out to compare the frequencies of common SULT1A1 and SULT1A2 alleles in Caucasian, Chinese and African-American subjects. Allele frequencies for SULT1A1*1, *2 and *3 in 242 Caucasian subjects were 0.656, 0.332 and 0.012, respectively. Frequencies of those same alleles were significantly different in 290 Chinese subjects: 0.914, 0.080 and 0.006, respectively, as were frequencies in 70 African-American subjects: 0.477, 0.294 and 0.229, respectively. Ethnic variation in allele frequencies was also observed for SULT1A2, with frequencies in Caucasian subjects for SULT1A2*1, *2 and *3 of 0.507, 0.389 and 0.104; frequencies in Chinese of 0.924 and 0.076 with no *3 alleles observed; and, finally, in African-Americans frequencies of 0.637, 0.249 and 0.114, respectively. We also found that SULT1A1*2 and SULT1A2*2, the most common variant alleles for these two genes, were in positive linkage disequilibrium in all three populations studied, with D' values of 0.776 in Caucasian (P < 0.001), 0.915 in Chinese (P < 0.001) and 0.864 in African-American subjects (P < 0.001). These observations represent a step towards determining the possible functional implications for individual variations in sulfate conjugation of common genetic polymorphisms for SULT1A1 and SULT1A2.