Evaluation of a patient navigation program to promote colorectal cancer screening in rural Georgia, USA

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer death in the United States. Early detection through recommended screening has been shown to have favorable treatment outcomes, yet screening rates among the medically underserved and uninsured are low, particularly for rural and minority populations. This study evaluated the effectiveness of a patient navigation program that addresses individual and systemic barriers to CRC screening for patients at rural, federally qualified community health centers.

METHODS

This quasi-experimental evaluation compared low-income patients at average risk for CRC (n = 809) from 4 intervention clinics and 9 comparison clinics. We abstracted medical chart data on patient demographics, CRC history and risk factors, and CRC screening referrals and examinations. Outcomes of interest were colonoscopy referral and examination during the study period and being compliant with recommended screening guidelines at the end of the study period. We conducted multilevel logistic analyses to evaluate the program's effectiveness.

RESULTS

Patients at intervention clinics were significantly more likely than patients at comparison clinics to undergo colonoscopy screening (35% versus 7%, odds ratio = 7.9, P < .01) and be guideline-compliant on at least one CRC screening test (43% versus 11%, odds ratio = 5.9, P < .001).

CONCLUSIONS

Patient navigation, delivered through the Community Cancer Screening Program, can be an effective approach to ensure that lifesaving, preventive health screenings are provided to low-income adults in a rural setting.

Training unemployed women for adult day care in Izmir, Turkey: a program evaluation

The proportion of older people in Turkey is increasing steadily with a subsequent growth of long-term care (LTC) needs. There is a scarcity of formal care provisions for residential and particularly nonresidential settings. Thus, formal caregiving is not meeting LTC needs nor attracting workers as a labor option. The authors examine the hypothesis that LTC may offer work opportunities for women unfamiliar with caregiving as an occupation, and also examine the need and acceptance of different types of LTC beyond residential care. The authors evaluate an innovative project introducing these two elements to 76 women in İzmir, Turkey, using an analysis framework that incorporates factors related to applications and progression; management assessment; trainees' self-assessment reflecting on their views on aging; and older people's perception of the experience and its impact on their well-being. Trainees reported a major positive shift in their attitudes toward working in LTC and toward the aging process. Users reported discovering a new dimension to care, which directly affected their quality of life. Overall, this community-based initiative appeared effective in enhancing the awareness of the concept of adult day centers providing a social model of care, and appears promising in addressing the growing need for formal LTC in Turkey.

Scaling up prevention of mother-to-child HIV transmission programs in sub-Saharan African countries: a multilevel assessment of site-, program- and country-level determinants of performance

BACKGROUND

Uptake of prevention of mother-to-child HIV transmission (PMTCT) programs remains challenging in sub-Saharan Africa because of multiple barriers operating at the individual or health facility levels. Less is known regarding the influence of program-level and contextual determinants. In this study, we explored the multilevel factors associated with coverage in single-dose nevirapine PMTCT programs.

METHODS

We analyzed aggregate routine data collected within the framework of the Viramune(®) Donation Programme (VDP) from 269 sites in 20 PMTCT programs and 15 sub-Saharan countries from 2002 to 2005. Site performance was measured using a nevirapine coverage ratio (NCR), defined as the reported number of women receiving nevirapine divided by the number of women who should have received nevirapine (observed HIV prevalence x number of women in antenatal care [ANC]). Data on program-level determinants were drawn from the initial application forms, and country-level determinants from the Demographic and Health Surveys (DHS) and the World Bank (World Development Indicators). Multilevel linear mixed models were used to identify independent factors associated with NCR at the site-, program- and country-level.

RESULTS

Of 283,410 pregnant women attending ANC in the included sites, 174,312 women (61.5%) underwent HIV testing after receiving pre-test counselling, of whom 26,700 tested HIV positive (15.3%), and 22,591 were dispensed NVP (84.6%). Site performance was highly heterogeneous between and within programs. Mean NCR by site was 43.8% (interquartile range: 19.1-63.9). Multilevel analysis identified higher HIV prevalence (Beta coefficient: 25.1, 95% confidence interval [CI] 18.7 to 31.6), higher proportion of persons with knowledge of PMTCT (8.3; CI 0.5 to 16.0), higher health expenditure as a proportion of Gross Domestic Product (3.9 per %; CI 2.0 to 5.8) and lower percentage of rural population (-0.7 per %; CI -1.0 to -0.5) as significant country-level predictors of higher NCR at the p<0.05 level. A medium ANC monthly activity (30-100/month) was the only site-level predictor found (-7.6; CI -15.1 to -0.1).

CONCLUSIONS

Heterogeneity of nevirapine coverage between sites and programs was high. Multilevel analysis identified several significant contextual determinants, which may warrant additional research to further define important multi-level and potentially modifiable determinants of performance of PMTCT programs.

Prolonged care management for depression: a case-controlled study of those enrolled for more than one year

INTRODUCTION

Collaborative care management (CCM) for the treatment of depression has been shown to be an effective therapy. CCM can be seen as a resource intensive treatment. Early identification of patients who would not be effectively treated with CCM could allow for alteration of therapy or change in modality.

METHODS

A retrospective case-controlled study used 132 patients with prolonged enrollment (>1 year) in CCM (cases) and 396 randomized CCM patients who achieved remission within 6 months (controls). The hypothesis was that by studying the epidemiology of patients in prolonged care management (PCM), characteristics could be determined to help define this group.

RESULTS

With regression modeling, the odds of a patient having PCM at 1 year was highly significant for those unmarried patients (odds ratio [OR] = 1.736, confidence interval [CI] = 1.115-2.703, P = .015) with dysthymia (OR = 2.362, CI = 1.104-5.052, P = .027) and severe depression (OR = 2.856, CI = 1.551-5.260, P = .001). The adjusted baseline Patient Health Questionnaire-9 (PHQ-9) score showed a difference of 16.0 for the cases versus 14.8 for the controls (P < .001). By 10 weeks, the difference is much larger at (10.7 vs 4.9, P < .001). At 26 weeks, the control group had an adjusted average PHQ-9 score of 2.0, whereas the case group was still elevated at 10.2 (P < .001).

CONCLUSIONS

Case-controlled analysis of PCM patients demonstrated independent predictors (such as unmarried status, diagnosis of dysthymia or severe depression), however, no baseline data was of sufficient clarity to suggest changes in clinical practice. The trend of the patient's PHQ-9 over time was strongly suggestive of allowing differentiation between the groups.

Evaluation of a federally funded workforce development program: the Centers for Public Health Preparedness

The Centers for Public Health Preparedness (CPHP) program was a five-year cooperative agreement funded by the Centers for Disease Control and Prevention (CDC). The program was initiated in 2004 to strengthen terrorism and emergency preparedness by linking academic expertise to state and local health agency needs. The purposes of the evaluation study were to identify the results achieved by the Centers and inform program planning for future programs. The evaluation was summative and retrospective in its design and focused on the aggregate outcomes of the CPHP program. The evaluation results indicated progress was achieved on program goals related to development of new training products, training members of the public health workforce, and expansion of partnerships between accredited schools of public health and state and local public health departments. Evaluation results, as well as methodological insights gleaned during the planning and conduct of the CPHP evaluation, were used to inform the design of the next iteration of the CPHP Program, the Preparedness and Emergency Response Learning Centers (PERLC).

Evaluation of CancerChatCanada: a program of online support for Canadians affected by cancer

BACKGROUND

Professional-led cancer support groups can improve quality of life and address unmet needs, but most Canadians affected by cancer do not have access to or do not make use of cancer support groups. A collaborative interdisciplinary team developed, operated, and evaluated Internet-based, professional-led, live-chat support groups (osgs) for cancer patients, caregivers, and survivors across Canada.

OBJECTIVE

Our study aimed to report participant and participation characteristics in the pan-Canadian initiative known as CancerChatCanada, and to understand participant perspectives about the quality of communication and professional facilitation, overall satisfaction, and psychosocial benefits and outcomes.

METHODS

Participants in osgs provided informed consent. Participant and participation characteristics were gathered from program data collection tools and are described using frequencies, means, and chi-squares. Patient, survivor, and caregiver perspectives were derived from 102 telephone interviews conducted after osg completion and subjected to a directed qualitative content analysis.

RESULTS

The 55 professional-led osgs enrolled 351 participants from 9 provinces. More than half the participants came from rural or semirural areas, and more than 84% had no received previous cancer support. The attendance rate was 75%, the dropout rate was 26%, and 80% of participants were satisfied or very satisfied. The convenience and privacy of osgs were benefits. Meaningful communication about important and difficult topics, kinship and bonding with others, and improved mood and self-care were perceived outcomes.

CONCLUSIONS

Our results demonstrate that this collaborative initiative was successful in increasing reach and access, and that pan-Canadian, professional-led osgs provide psychosocial benefit to underserved and burdened cancer patients, survivors, and family caregivers.

Using the objective structured clinical examinations in undergraduate midwifery students

The Objective Structured Clinical Examination (OSCE) has been considered a modern type of examination for the assessment of clinical skills within nurse education, but it has been rarely applied in the teaching of midwifery. The aim of the present study was to assess the use of the OSCE as a tool to evaluate the abilities of undergraduate midwifery students and to compare the perspectives of the students regarding the OSCE and traditional examination. Fifty-two midwifery students participated in the study. The export trainer evaluated the internal consistency of the OSCE stations and it was tested by using Cronbach's alpha. Successive groups of students completed a self-administered questionnaire immediately after the final examination. The students' perspective regarding the traditional final examination ranked as unsatisfactory by more than two thirds of the students, while, the students' perspective regarding the OSCE system was ranked as very satisfactory to satisfactory by more than half of the students (p=0.001). There was a significant difference in the students' perspective between the OSCE system and the traditional final examination among the students (49.8±18.3 vs 25.3±18.1) (p=0.001). A significant difference was found in being credible (p=0.0001), consistent/reliable (p=0.001), enhances teaching level (p=0.011), and measures the course category (p=0.008) between two methods of the final examination. Around half of the students expressed their opinion that the OSCE test was a stressful assessment. Overall, students' evaluation of the OSCE was remarkably encouraging. To this end, we recommend the consideration of the validity and reliability of the process for undergraduate midwifery students.

Does providing care for uninsured patients decrease emergency room visits and hospitalizations?

BACKGROUND

Access to primary care could reduce use of more costly health care by uninsured individuals through prevention and early treatment. We analyzed data from a program providing free primary care to test this hypothesis.

METHODS

We compared emergency room (ER) visits and hospitalizations among uninsured, low-income adults who received immediate versus delayed access to a program providing free primary care, including labs, X-rays, and specialty consultation. We used surveys to identify ER visits and hospitalizations during the 12 months preceding and following program enrollment or wait list entry.

RESULTS

Hospitalizations decreased from the year before entry to the year following entry in participants with immediate and delayed (6.0% vs 8.8% decrease) access. ER use also decreased in both groups (11.2% vs 15.4%).

CONCLUSIONS

Free primary care services and specialty consultation did not reduce use of more costly health care services during its first year. More prolonged availability of primary care might have greater impact.

The double task of preventing malnutrition and overweight: a quasi-experimental community-based trial

BACKGROUND

The Maternal-Child Pastoral is a volunteer-based community organization of the Dominican Republic that works with families to improve child survival and development. A program that promotes key practices of maternal and child care through meetings with pregnant women and home visits to promote child growth and development was designed and implemented. This study aims to evaluate the impact of the program on nutritional status indicators of children in the first two years of age.

METHODS

A quasi-experimental design was used, with groups paired according to a socioeconomic index, comparing eight geographical areas of intervention with eight control areas. The intervention was carried out by lay health volunteers. Mothers in the intervention areas received home visits each month and participated in a group activity held biweekly during pregnancy and monthly after birth. The primary outcomes were length and body mass index for age. Statistical analyses were based on linear and logistic regression models.

RESULTS

196 children in the intervention group and 263 in the control group were evaluated. The intervention did not show statistically significant effects on length, but point estimates found were in the desired direction: mean difference 0.21 (95%CI -0.02; 0.44) for length-for-age Z-score and OR 0.50 (95%CI 0.22; 1.10) for stunting. Significant reductions of BMI-for-age Z-score (-0.31, 95%CI -0.49; -0.12) and of BMI-for-age > 85th percentile (0.43, 95%CI 0.23; 0.77) were observed. The intervention showed positive effects in some indicators of intermediary factors such as growth monitoring, health promotion activities, micronutrient supplementation, exclusive breastfeeding and complementary feeding.

CONCLUSIONS

Despite finding effect measures pointing to effects in the desired direction related to malnutrition, we could only detect a reduction in the risk of overweight attributable to the intervention. The findings related to obesity prevention may be of interest in the context of the nutritional transition. Given the size of this study, the results are encouraging and we believe a larger study is warranted.

Community-based participatory evaluation: the healthy start approach

The use of community-based participatory research has gained momentum as a viable approach to academic and community engagement for research over the past 20 years. This article discusses an approach for extending the process with an emphasis on evaluation of a community partnership-driven initiative and thus advances the concept of conducting community-based participatory evaluation (CBPE) through a model used by the Healthy Start project of the Augusta Partnership for Children, Inc., in Augusta, Georgia. Application of the CBPE approach advances the importance of bilateral engagements with consumers and academic evaluators. The CBPE model shows promise as a reliable and credible evaluation approach for community-level assessment of health promotion programs.

Evaluation of an HIV prevention intervention designed for African American Women: results from the SISTA Community-Based Organization Behavioral Outcomes Project

One of the Centers for Disease Control and Prevention's strategies for addressing racial disparities within the HIV epidemic is to support the implementation of HIV prevention behavioral interventions designed for African Americans. One such intervention is Sisters Informing Sisters about Topics on AIDS (SISTA), a culturally relevant and gender-specific, five-session, group-level, HIV prevention intervention designed for African American women. In 2008, the Centers for Disease Control and Prevention funded five community-based organizations to conduct outcome monitoring of SISTA to assess the outcomes associated with implementation in the field. Using a 90-day recall, demographic and sexual risk data were collected from participants at baseline and at 90 and 180 days post-intervention. Findings reveal that women participating in SISTA (n = 432) demonstrated a significant reduction in sexual risk between baseline and both follow-up time points for each of the six outcomes being measured (e.g., any unprotected sex, all protected sex).

The Child and Adult Care Food Program and the Nutrition of Preschoolers

Children spend a considerable amount of time in preschools and child care centers. As a result, these settings may have an influence on their diet, weight, and food security, and are potentially important contexts for interventions to address nutritional health. The Child and Adult Care Food Program (CACFP) is one such intervention. No national study has compared nutrition-related outcomes of children in CACFP-participating centers to those of similar children in non-participating centers. We use a sample of four-year old children drawn from the Early Childhood Longitudinal Study, Birth Cohort to obtain estimates of associations between CACFP program participation and consumption of milk, fruits, vegetables, fast food, and sweets, and indicators of overweight, underweight status and food insecurity. We find that, among low-income children, CACFP participation moderately increases consumption of milk and vegetables, and may also reduce the prevalence of overweight and underweight. Effects on other outcomes are generally small and not statistically significant.

Interventions for recruiting smokers into cessation programmes

BACKGROUND

Tobacco control is a top public health priority around the globe due to the high prevalence of cigarette smoking and its associated morbidity and mortality. Much effort has been focused on establishing the effectiveness of different smoking cessation strategies. This review, however, aims to address the initial challenge faced by smoking cessation programmes: recruitment of smokers.

OBJECTIVES

The primary objective of this review was to determine the effectiveness of different strategies for recruiting smokers into cessation programmes. The secondary objective was to determine the impact that these strategies had on smoking cessation rates at least six months after enrolment into a cessation programme.

SEARCH METHODS

We searched the specialised register of the Cochrane Tobacco Addiction Group using a search strategy which included the terms ('recruit$', 'invit$', 'enter', 'entry', 'enrolment') combined with ('smok$', 'cigarette', 'smoking cessation', 'tobacco') in the title, abstract or keyword fields. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and registers of current and ongoing trials. We also searched the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials and cluster randomised controlled trials that compared at least two different methods of recruiting current smokers into a smoking cessation programme. We also included those studies which focused on the effectiveness of a smoking cessation programme as long as the study involved multiple recruitment methods and reported results of the recruitment phase.

DATA COLLECTION AND ANALYSIS

From each included study, we extracted data on the type of participants, type of recruitment strategies (i.e., setting, mode of communication used, intensity and duration) and comparisons, and on randomisation, allocation concealment, and blinding procedures.Our primary outcome was the proportion of smokers successfully recruited to each cessation programme compared to alternative modalities of recruitment. Our secondary outcome was smoking cessation for at least six months. Given the substantial heterogeneity across recruitment interventions and participants, we adopted a narrative synthesis approach for summarising results.

MAIN RESULTS

This review includes 19 studies with a total of 14,890 participants. We categorised the included studies according to the modes used to deliver the recruitment strategy: head to head comparison of individual recruitment strategies; comparison of the same delivery mode but with different content or intensity; and the addition of another mode to an existing recruitment method.We identified three studies that made head-to-head comparisons of different types of recruitment strategies. Of these, only one study detected a significant effect, finding that a personal phone call was more effective than a generic invitation letter (RR 40.73, 95% CI 2.53 to 654.74). Five studies compared interventions using the same delivery modes but different content. Results showed that tailored messages through an interactive voice response system resulted in a higher recruitment rate than assessment of smoking status alone using the same system (RR 8.64, 95% CI 4.41 to 16.93), and that text messages indicating scarcity of places available were more effective than generic text message reminders (RR 1.45, 95% CI 1.07 to 1.96). One study compared interventions using the same delivery mode but different intensity and found that allowing for more phone call attempts to reach potential participants can result in better recruitment (RR 1.87, 95% CI 1.61 to 2.18). Finally, 10 studies investigated the effect of adding a recruitment mode to existing recruitment strategies. Findings showed that: adding a text message reminder or real quotes from participants to a personal phone call improved recruitment of participants (RR 3.38, 95% CI 1.26 to 9.08 and RR 29.07, 95% CI 1.74 to 485.70, respectively); that adding a personal phone call to an existing newsletter can also increase recruitment rates (RR 65.12, 95% CI 4.06 to 1045.4]); that a reactive-proactive recruitment phase is more effective than a proactive phase alone (63.8% versus 47.5%, RR not available); and that active recruitment at schools is more effective than passive recruitment (p < 0.001, denominator not available for calculation of RR). Additionally, a number of studies in this category showed that providing incentives can effectively increase the number of participants recruited into smoking cessation programmes.Out of the 19 included studies, only four reported on the effect of recruitment strategy on smoking cessation at six months or longer. Three of these studies compared strategies that used the same delivery mode with different content. Their results were non-significant. The remaining three studies evaluated adding an additional mode to an existing recruitment intervention. Only one of them showed a significant difference in the levels of smoking cessation that favoured the enhanced recruitment strategy, but this may have reflected the offer of incentives once in the programme rather than the recruitment strategy itself (RR at 15 or 18 months 2.60, 95% CI 1.48 to 4.56).

AUTHORS' CONCLUSIONS

The substantial heterogeneity across the included studies restricts our ability to draw firm conclusions about the effectiveness of different recruitment strategies in relation to recruitment of participants into smoking cessation programmes or levels of smoking cessation. The limited evidence, however, suggests that the following elements may improve the recruitment of smokers into cessation programmes: personal, tailored interventions; recruitment methods that are proactive in nature; and more intensive recruitment strategies (i.e., those strategies that require increased contact with potential participants).

Curricular integration in pharmacy education

This article reviews the concepts of curricular integration and integrative learning. These concepts have reemerged in contemporary higher education reforms and are crucial in pharmacy programs where students are expected to acquire the knowledge, skills, and abilities needed for competent practice in a complex environment. Enhancing integration requires negotiating obstacles, including institutional traditions of disciplinary structures and disciplinary differences in understandings of knowledge and approaches to teaching and learning; investing the time and effort to design and implement integrated curricula; and using learning-centered pedagogical strategies. Evidence supporting the value of such efforts is not compelling, as much because of insufficient research as lackluster findings. Future avenues of scholarly inquiry are suggested to evaluate curricular integration, distinguishing between the curriculum espoused by planners, the curriculum enacted by instructors, and the curriculum experienced by students.

Building the evidence base for chronic disease self-management support interventions across Canada

OBJECTIVE

The objective of this project was to determine how to improve evaluation of self-management support (SMS) in Canada to generate high-quality evidence to guide policy-makers, implementers, providers and participants.

METHODS

This project used a multi-method approach, including a scoping and a focused literature review, an internet scan, interviews with key stakeholders, a review of existing theoretical evaluation frameworks and a consensus meeting with experts.

RESULTS

Four themes were identified through the collection and analysis of data: 1) diverse SMS interventions are identifiable; 2) emerging evaluation activity in Canada is limited to mostly disease-specific, clinic-based programs; 3) there is little evaluation capacity among program implementers in Canada; and 4) there is a gap between the evidence and expectations.

CONCLUSION

Policy-makers, community organizations and health care teams, regional health authorities and, most importantly, people living with chronic conditions, need better evidence about how to support self-management in their communities. Measuring outcomes must be an explicit part of program implementation and development and requires coordinated support. A common evaluation framework may provide researchers, practitioners and decision- or policy-makers with a systems approach to understanding the possible structural and process factors that can affect self-management outcomes, and could support capacity building in evaluation.

Exploring transitions within a project-based Housing First setting: qualitative evaluation and practice implications

The Housing First (HF) approach is a model of housing that entails the provision of immediate, permanent, low-barrier, supportive housing to chronically homeless individuals either in separate apartments within a larger community (known as scattered-site HF) or in a single building (known as project-based HF). One recent innovation is the application of project-based HF with chronically homeless individuals with alcohol problems. Although initial studies have shown its effectiveness, there is currently no research on residents' and staff 's experiences living and working in a project-based HF program. The purpose of this article was to document these experiences and highlight strengths and challenges of project-based HF programs. Using data collected from naturalistic observations, agency documentation, one-on-one resident interviews, and a staff focus group, we delineated transitional periods, including moving into project-based HF, community-building, managing day-to-day, and transitions from project-based HF. Findings are interpreted to help health care policymakers and providers envision the role of project-based HF in comprehensive public health efforts and to integrate lessons learned into their own clinical practice.

Evaluating the dissemination of Body & Soul, an evidence-based fruit and vegetable intake intervention: challenges for dissemination and implementation research

OBJECTIVE

To evaluate whether the evidence-based Body & Soul program, when disseminated and implemented without researcher or agency involvement and support, would achieve results similar to those of earlier efficacy and effectiveness trials.

DESIGN

Prospective group randomized trial.

SETTING

Churches with predominantly African American membership.

PARTICIPANTS

A total of 1,033 members from the 15 churches completed baseline surveys. Of these participants, 562 (54.4%) completed the follow-up survey 6 months later.

INTERVENTION

Church-based nutrition program for African Americans that included pastoral involvement, educational activities, church environmental changes, and peer counseling.

MAIN OUTCOME MEASURE

Daily fruit and vegetable (FV) intake was assessed at pre- and posttest.

ANALYSIS

Mixed-effects linear models.

RESULTS

At posttest, there was no statistically significant difference in daily servings of FVs between the early intervention group participants compared to control group participants (4.7 vs 4.4, P = .38). Process evaluation suggested that added resources such as technical assistance could improve program implementation.

CONCLUSIONS AND IMPLICATIONS

The disseminated program may not produce improvements in FV intake equal to those in the earlier efficacy and effectiveness trials, primarily because of a lack of program implementation. Program dissemination may not achieve public health impact unless support systems are strengthened for adequate implementation at the church level.

Male involvement for increasing the effectiveness of prevention of mother-to-child HIV transmission (PMTCT) programmes

BACKGROUND

Despite efforts to increase the uptake of prevention of mother to child transmission of HIV (PMTCT) services, coverage is still lower than desired in developing countries. A lack of male partner involvement in PMTCT services is a major barrier for women to access these services.

OBJECTIVES

To evaluate the impact of interventions which aim to enhance male involvement to increase women's uptake of PMTCT interventions in developing countries.

SEARCH METHODS

We searched the following databases from the year 2000 to November 2011: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, the WHO Global Health Library, ClinicalTrials.gov, Current Controlled Trials, AEGIS, CROI, IAS, IAC web sites.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-randomised controlled trials, quasi-randomised controlled trials, controlled before and after studies and interrupted time series studies assessing interventions to increase male involvement for improvement of uptake PMTCT services in low- and middle-income countries..

DATA COLLECTION AND ANALYSIS

Two reviewers independently searched, screened, assessed study quality and extracted data. A third reviewer resolved any disagreement.

MAIN RESULTS

Only one study met the inclusion criteria, an RCT conducted in Tanzania between May 2003 and October 2004. Women in the intervention group (n=760) received a letter for their male partners, which invited them to return together to receive Couple Voluntary Counselling and Testing (CVCT) for HIV. Women in the control group (n=761) received individual HIV VCT during their first ANC visit and then usual care. The percentages of women who received HIV VCT and collected their results were 48%, 45% and 39% in the intervention group and 93%, 78% and 71% in the control group (p <0,001). Only 33% of women in the intervention group returned with their male partners and only 47% of them went through the whole CVCT process. The proportion of women who received HIV prophylaxis at delivery was not different between the two arms (27% in the intervention and 22% in the control group). The study had a high risk of bias.  

AUTHORS' CONCLUSIONS

We found only one eligible study that assessed the effectiveness of male involvement in improving women's uptake of PMTCT services, which only focused on one part of the perinatal PMTCT cascade. We urgently need more rigorously designed studies assessing the impact of male engagement interventions on women's uptake of PMTCT services to know if this intervention can contribute to improve uptake of PMTCT services and reduce vertical transmission of HIV in children.   

Reliability of a telemedicine system designed for rural Kenya

OBJECTIVE

Access to health care in rural areas of developing nations is hindered by both the lack of physicians and the preference of many physicians to practice in urban settings. As a result, rural patients often choose not to sacrifice wages or time to visit distant health care providers. A telemedicine system, Mashavu: Networked Health Solutions, designed to increase access to preprimary health care in rural areas, was field-tested in rural Kenya. This study aims to examine the reliability of the system compared to the traditional face-to-face method of health care delivery.

METHOD

Reliability of the telemedicine system was tested using a modified intraobserver concordance study. Community health workers operated the system in various remote locations. Patient health information including chief complaint, medical history, and vital statistics were sent via Internet to a consulting nurse. After patients completed the telemedicine consultation, they also met in-person with the same nurse. Subsequently, the nurse's advice during the in-person session was compared with his feedback provided through the telemedicine consultation.

RESULTS

When comparing the nurse's advice given through the telemedicine system with the advice given through more traditional face-to-face, in-person consultation, the nurse provided consistent medical feedback in 78.4% of the cases (n = 102). The nurse's advice regarding patient action (eg, clinical referrals or no further care necessary) was the same in 89.2% of the cases (n = 91).

CONCLUSION

The study found that this telemedicine system was able to provide patients with approximately the same quality of care and advice as if the patient had physically travelled to a clinic to see a nurse. In rural areas of developing nations where there are high logistical and economical barriers to accessing health care, this telemedicine system successfully increased the ease and lowered the cost of connecting rural patients with nurses to provide preprimary care.

How to Effectively Monitor and Evaluate NCD Programmes in India

Program monitoring and evaluation (M and E) are important components of any program and are critical to sound strategic planning. The Ministry of Health and Family Welfare, Government of India, launched the National Programme for Prevention and Control of Cancer, Diabetes, Cardio-vascular diseases and Stroke (NPCDCS) with the objectives to prevent and control common noncommunicable diseases (NCDs) through behaviour and lifestyle changes, and to provide early diagnosis and management of common NCDs. M and E of program requires identification of indicators that measure inputs, process, outputs, and outcomes. The frequency of collecting information for these indicators will vary depending on the level of use and type of indicator as well as time interval over which we expect to see a change in that parameter. A group of indicators for different domains in the three major strategies has been proposed. For effective monitoring and evaluation of NPCDCS, the way forward is to finalize the list of indicators; evolve sustainable systems for surveillance; collect baseline assessment of the indicators at district level; fix targets for each indicator for different time frames; periodic review at state and national level for monitoring progress; and establish external review mechanisms. Monitoring and evaluation require complex set of co-ordinated action, responsibility for which has to be taken up by the NCD Cell within the Ministries of Health at state and national level. However, the routine data collection and compilation could be the responsibility of Central Bureau of Health Intelligence. Integrated population-based surveys with existing disease and behaviour surveillance could be undertaken by National Centre for Disease Control. The national NCD cell should compile all these information into a meaningful policy brief so that appropriate programmatic interventions can be identified. The launch of a national program to tackle the burden of NCDs is just the beginning, and the final success of the program will depend on how effectively we monitor and evaluate it.

Program evaluation of Sea Mar's Chronic Care Program for Latino and Caucasian patients with type 2 diabetes: providers and staff perspectives

Problem statement

Unprecedented consumption of health care resources in the USA coupled with increasing rates of chronic disease has fueled pursuit of improved models of health care delivery. The Chronic Care Model provides an organizational framework for chronic care management and practice improvement. Sea Mar, a community health care organization in Washington state, implemented the Chronic Care Model, but has not evaluated the outcomes related to provider and staff satisfaction. The specific aim of this project was to evaluate the effectiveness of the Chronic Care Model with the addition of the Chronic Care Coordinator role.

Approach

A descriptive method was used, which incorporated quantitative, and qualitative data from providers and clinic staff collected through a Web-based survey consisting of Likert-type questions sent via an electronic link.

Results

This evaluation identified the strengths of and barriers to the chronic care model with a focus on provider and staff satisfaction regarding patient care since the addition of the Chronic Care Coordinator role. We found a high appreciation (94%) and acceptance of the role; 80% agreed that the Chronic Care Coordinator was well-integrated into clinic operations. Major strengths of the program included more patient education, better follow-up, and improved team communications. Barriers to success included limited provider access, confusion regarding role expectations of the Chronic Care Coordinator, inconsistent communications, and Chronic Care Coordinator turnover.

Conclusions/recommendations

Our findings help to validate the importance of community health organizations such as Sea Mar, the utility of the chronic care model, and the potential value for specific roles such as the Chronic Care Coordinator to positively impact quality of care by helping to empower patients to improve self-management and ultimately impact patient outcomes. However, future studies involving larger samples are needed to further explore themes among staff and patients.

A systematic review of hand hygiene improvement strategies: a behavioural approach

BACKGROUND

Many strategies have been designed and evaluated to address the problem of low hand hygiene (HH) compliance. Which of these strategies are most effective and how they work is still unclear. Here we describe frequently used improvement strategies and related determinants of behaviour change that prompt good HH behaviour to provide a better overview of the choice and content of such strategies.

METHODS

Systematic searches of experimental and quasi-experimental research on HH improvement strategies were conducted in Medline, Embase, CINAHL, and Cochrane databases from January 2000 to November 2009. First, we extracted the study characteristics using the EPOC Data Collection Checklist, including study objectives, setting, study design, target population, outcome measures, description of the intervention, analysis, and results. Second, we used the Taxonomy of Behavioural Change Techniques to identify targeted determinants.

RESULTS

We reviewed 41 studies. The most frequently addressed determinants were knowledge, awareness, action control, and facilitation of behaviour. Fewer studies addressed social influence, attitude, self-efficacy, and intention. Thirteen studies used a controlled design to measure the effects of HH improvement strategies on HH behaviour. The effectiveness of the strategies varied substantially, but most controlled studies showed positive results. The median effect size of these strategies increased from 17.6 (relative difference) addressing one determinant to 49.5 for the studies that addressed five determinants.

CONCLUSIONS

By focussing on determinants of behaviour change, we found hidden and valuable components in HH improvement strategies. Addressing only determinants such as knowledge, awareness, action control, and facilitation is not enough to change HH behaviour. Addressing combinations of different determinants showed better results. This indicates that we should be more creative in the application of alternative improvement activities addressing determinants such as social influence, attitude, self-efficacy, or intention.

Adaptation and validation of the Japanese version of the Health Education Impact Questionnaire (heiQ-J) for the evaluation of self-management education interventions

AIM

In many countries, health education interventions are popular; however, few valid measures exist for evaluation of multifactorial interventions. The aim of the present study was to translate and culturally adapt the widely-used 8 scale Health Education Impact Questionnaire (heiQ) for the evaluation of the Japanese Specific Health Consultation (SHC) in people with metabolic syndrome.

METHODS

A draft was generated using a standardized forward and back translation protocol with independent translators and consensus meetings. Pilot testing included cognitive interviews (n = 12) resulting in question refinements. To explore psychometric properties, 250 participants aged between 40 and 64 years (retest = 116) completed the Japanese version of the heiQ (heiQ-J) and comparator scales, mental health and vitality scales of the Medical Outcomes Study 36 item Short-Form Health Survey, Sense Of Coherence scale, and Social Support Measurement scale.

RESULTS

Cognitive interviews revealed that the translation was understood as intended by participants. Internal consistency (α) was good to very good for all scales (0.70-0.88) and test-retest intraclass correlation coefficients were high (≥ 0.83). Concurrent validity was supported by high correlation with like scales and weak correlation with dissimilar scales.

CONCLUSION

The translated and adapted heiQ-J has good face and concurrent validity and is reliable. The heiQ-J is likely to be a useful measure of the quality and impact of the SHC and return valuable data to clinicians and commissioners of health education in Japan.

The role of matched controls in building an evidence base for hospital-avoidance schemes: a retrospective evaluation

OBJECTIVE

To test whether two hospital-avoidance interventions altered rates of hospital use: "intermediate care" and "integrated care teams."

DATA SOURCES/STUDY SETTING

Linked administrative data for England covering the period 2004 to 2009.

STUDY DESIGN

This study was commissioned after the interventions had been in place for several years. We developed a method based on retrospective analysis of person-level data comparing health care use of participants with that of prognostically matched controls.

DATA COLLECTION/EXTRACTION METHODS

Individuals were linked to administrative datasets through a trusted intermediary and a unique patient identifier.

PRINCIPAL FINDINGS

Participants who received the intermediate care intervention showed higher rates of unscheduled hospital admission than matched controls, whereas recipients of the integrated care team intervention showed no difference. Both intervention groups showed higher rates of mortality than did their matched controls.

CONCLUSIONS

These are potentially powerful techniques for assessing impacts on hospital activity. Neither intervention reduced admission rates. Although our analysis of hospital utilization controlled for a wide range of observable characteristics, the difference in mortality rates suggests that some residual confounding is likely. Evaluation is constrained when performed retrospectively, and careful interpretation is needed.

Immunization completeness of children under two years of age in Nova Scotia, Canada

OBJECTIVES

Canada's progress in establishing a national immunization registry and coordinated immunization schedule across provinces has been slow. The absence of a centralized registry means there are only limited data available on childhood immunization coverage in Canada. The aim of this study was to estimate the completeness and timeliness of immunization for two year-old children in Nova Scotia.

METHODS

The study included 8,245 babies born in Nova Scotia during 2006. Immunization data were derived from three sources: Provincial Medical Insurance Physician Billing data, public health records, and self-report by parents. Immunization uptake rates for vaccines included in the Nova Scotia immunization schedule were calculated at ages 12, 18 and 24 months. Logistic regression was used to analyze vaccine uptake in relation to socio-economic factors. A telephone survey of a sample of parents of study children was completed.

RESULTS

The overall immunization completeness rate was 49% at 12 months, 40% at 18 months and 58% at 24 months of age. Immunization completeness was significantly higher in more socially disadvantaged communities.

CONCLUSIONS

Nova Scotia spends many millions of dollars on vaccine purchase and administration, but, as with numerous Canadian jurisdictions, there is no accurate system for monitoring or evaluating the program. The timeliness and completeness of immunization administration to pre-school children in Nova Scotia is inadequate. Further work should elucidate the barriers and enablers to immunization to ensure that public health education targets those most likely to be under-immunized. A provincial vaccination database should be established to monitor and evaluate the system.

Assessment of eight HPV vaccination programs implemented in lowest income countries

BACKGROUND

Cervix cancer, preventable, continues to be the third most common cancer in women worldwide, especially in lowest income countries. Prophylactic HPV vaccination should help to reduce the morbidity and mortality associated with cervical cancer. The purpose of the study was to describe the results of and key concerns in eight HPV vaccination programs conducted in seven lowest income countries through the Gardasil Access Program (GAP).

METHODS

The GAP provides free HPV vaccine to organizations and institutions in lowest income countries. The HPV vaccination programs were entirely developed, implemented and managed by local institutions. Institutions submitted application forms with institution characteristics, target population, communication delivery strategies. After completion of the vaccination campaign (3 doses), institutions provided a final project report with data on doses administered and vaccination models. Two indicators were calculated, the program vaccination coverage and adherence. Qualitative data were also collected in the following areas: government and community involvement; communication, and sensitization; training and logistics resources, and challenges.

RESULTS

A total of eight programs were implemented in seven countries. The eight programs initially targeted a total of 87,580 girls, of which 76,983 received the full 3-dose vaccine course, with mean program vaccination coverage of 87.8%; the mean adherence between the first and third doses of vaccine was 90.9%. Three programs used school-based delivery models, 2 used health facility-based models, and 3 used mixed models that included schools and health facilities. Models that included school-based vaccination were most effective at reaching girls aged 9-13 years. Mixed models comprising school and health facility-based vaccination had better overall performance compared with models using just one of the methods. Increased rates of program coverage and adherence were positively correlated with the number of vaccination sites. Qualitative key insights from the school models showed a high level of coordination and logistics to facilitate vaccination administration, a lower risk of girls being lost to follow-up and vaccinations conducted within the academic year limit the number of girls lost to follow-up.

CONCLUSION

Mixed models that incorporate both schools and health facilities appear to be the most effective at delivering HPV vaccine. This study provides lessons for development of public health programs and policies as countries go forward in national decision-making for HPV vaccination.

Life skills programmes for chronic mental illnesses

BACKGROUND

Most people with schizophrenia have a cyclical pattern of illness characterised by remission and relapses. The illness can reduce the ability of self-care and functioning and can lead to the illness becoming disabling. Life skills programmes, emphasising the needs associated with independent functioning, are often a part of the rehabilitation process. These programmes have been developed to enhance independent living and quality of life for people with schizophrenia.

OBJECTIVES

To review the effects of life skills programmes compared with standard care or other comparable therapies for people with chronic mental health problems.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (June 2010). We supplemented this process with handsearching and scrutiny of references. We inspected references of all included studies for further trials.

SELECTION CRITERIA

We included all relevant randomised or quasi-randomised controlled trials for life skills programmes versus other comparable therapies or standard care involving people with serious mental illnesses.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a random-effects model. For continuous data, we calculated mean differences (MD), again based on a random-effects model.

MAIN RESULTS

We included seven randomised controlled trials with a total of 483 participants. These evaluated life skills programmes versus standard care, or support group. We found no significant difference in life skills performance between people given life skills training and standard care (1 RCT, n = 32, MD -1.10; 95% CI -7.82 to 5.62). Life skills training did not improve or worsen study retention (5 RCTs, n = 345, RR 1.16; 95% CI 0.40 to 3.36). We found no significant difference in PANSS positive, negative or total scores between life skills intervention and standard care. We found quality of life scores to be equivocal between participants given life skills training (1 RCT, n = 32, MD -0.02; 95% CI -0.07 to 0.03) and standard care. Life skills compared with support groups also did not reveal any significant differences in PANSS scores, quality of life, or social performance skills (1 RCT, n = 158, MD -0.90; 95% CI -3.39 to 1.59).

AUTHORS' CONCLUSIONS

Currently there is no good evidence to suggest life skills programmes are effective for people with chronic mental illnesses. More robust data are needed from studies that are adequately powered to determine whether life skills training is beneficial for people with chronic mental health problems.

Long-term residential substance abuse treatment for women: lessons learned from Israel

Background

Policymakers and treatment providers must consider the role of gender when designing effective treatment programs for female substance abusers. This study had two aims. First, to examine female substance abusers’ perceptions regarding factors that contribute to their retention (and therefore positive treatment outcomes) in a women-only therapeutic community in Northern Israel. Second, to explore pretreatment internal and external factors including demographic, personal and environmental factors, factors associated with substance use and with the treatment process, and networks of support that contribute to retention and abstinence.

Methods

The study was a conducted using a mixed methods approach. Semi-structured qualitative interviews examining perceptions towards treatment were conducted in five focus groups (n = 5 per group; total n = 25). Intake assessments and a battery of questionnaires examining pretreatment internal and external factors related to treatment retention and abstinence were collected from 42 women who were treated in the program during the 2 year study period. Twenty-three women who completed the 12 month program were compared to the 19 women who did not, using chi-square for categorical variables and t-tests for continuous variables. Nineteen of the 23 women who completed the questionnaires also completed a post-treatment follow-up questionnaire.

Results

A content analysis of the interviews revealed five central themes: factors associated with treatment entry; impact of treatment in a women-only setting; significant aspects of treatment; difficulties with the setting; prospects for the future. Analysis of the questionnaires revealed that compared to non-completers, completers had fewer psychiatric symptoms, higher levels of introverted behavior in stressful situations, a better sense of coherence, and less ability to share emotions. No significant differences were found with regard to demographic and substance use factors. All 19 women who completed treatment and the follow-up questionnaire remained abstinent from illicit drugs for 18 months following the end of treatment.

Conclusion

Results indicate that women see the women-only treatment setting as extremely significant. Also, there is a profile of psychiatric co-morbidity, extrapunitiveness, and fewer personal resources that predict a risk for attrition. Thus, women at risk for attrition may be identified early and treatment staff can utilize the results to assist clients in achieving their treatment goals. Results can inform policymakers in making decisions regarding the allocation of resources, by pointing to the importance of long-term women-only residential treatment in increasing positive treatment outcomes.

The impact of psychiatric diagnosis on treatment adherence and duration among victimized children and adolescents in São Paulo, Brazil

OBJECTIVE

Despite the high prevalence of substance abuse and mood disorders among victimized children and adolescents, few studies have investigated the association of these disorders with treatment adherence, represented by numbers of visits per month and treatment duration. We aimed to investigate the effects of substance abuse and mood disorders on treatment adherence and duration in a special program for victimized children in São Paulo, Brazil.

METHODS

A total of 351 participants were evaluated for psychiatric disorders and classified into one of five groups: mood disorders alone; substance abuse disorders alone; mood and substance abuse disorders; other psychiatric disorders; no psychiatric disorders. The associations between diagnostic classification and adherence to treatment and the duration of program participation were tested with logistic regression and survival analysis, respectively.

RESULTS

Children with mood disorders alone had the highest rate of adherence (79.5%); those with substance abuse disorders alone had the lowest (40%); and those with both disorders had an intermediate rate of adherence (50%). Those with other psychiatric disorders and no psychiatric disorders also had high rates of adherence (75.6% and 72.9%, respectively). Living with family significantly increased adherence for children with substance abuse disorders but decreased adherence for those with no psychiatric disorders. The diagnostic correlates of duration of participation were similar to those for adherence.

CONCLUSIONS

Mood and substance abuse disorders were strong predictive factors for treatment adherence and duration, albeit in opposite directions. Living with family seems to have a positive effect on treatment adherence for patients with substance abuse disorders. More effective treatment is needed for victimized substance-abusing youth.

Design and evaluation of a theory-based, culturally relevant outreach model for breast and cervical cancer screening for Latina immigrants

OBJECTIVES

Breast and cervical cancer are common among Latinas, but screening rates among foreign-born Latinas are relatively low. In this article we describe the design and implementation of a theory-based (PEN-3) outreach program to promote breast and cervical cancer screening to Latina immigrants, and evaluate the program's effectiveness.

METHODS

We used data from self-administered questionnaires completed at six annual outreach events to examine the sociodemographic characteristics of attendees and evaluate whether the program reached the priority population - foreign-born Latina immigrants with limited access to health care and screening services. To evaluate the program's effectiveness in connecting women to screening, we examined the proportion and characteristics of women who scheduled and attended Pap smear and mammography appointments.

RESULTS

Among the 782 Latinas who attended the outreach program, 60% and 83% had not had a Pap smear or mammogram, respectively, in at least a year. Overall, 80% scheduled a Pap smear and 78% scheduled a mammogram. Women without insurance, who did not know where to get screening and had not been screened in the last year were more likely to schedule appointments (P < .05). Among women who scheduled appointments, 65% attended their Pap smear and 79% attended the mammogram. We did not identify significant differences in sociodemographic characteristics associated with appointment attendance.

CONCLUSIONS

Using a theoretical approach to outreach design and implementation, it is possible to reach a substantial number of Latina immigrants and connect them to cancer screening services.

Exploring the Value Added of a Guided, Silent Reading Intervention: Effects on Struggling Third-Grade Readers' Achievement

The authors' purpose was to explore the effects of a supplementary, guided, silent reading intervention with 80 struggling third-grade readers who were retained at grade level as a result of poor performance on the reading portion of a criterion referenced state assessment. The students were distributed in 11 elementary schools in a large, urban school district in the state of Florida. A matched, quasi-experimental design was constructed using propensity scores for this study. Students in the guided, silent reading intervention, Reading Plus, evidenced higher, statistically significant mean scores on the Florida Comprehensive Assessment Test criterion assessment measure of reading at posttest. The effect size, favoring the guided, silent reading intervention group was large, 1 full standard deviation, when comparing the 2 comparison groups' mean posttest scores. As such, the results indicate a large advantage for providing struggling third-grade readers guided silent reading fluency practice in a computer-based practice environment. No significant difference was found between the treatment and control group on the Stanford Achievement Test-10 (SAT-10) posttest scores, although posttest scores for the treatment group trended higher than the control. After conducting a power analysis, it was determined that the sample size (n = 80) was too small to provide sufficient statistical power to detect a difference in third-grade students' SAT-10 scores.

Developing a measure to evaluate a positive youth development program for Native Hawaiians: the Hui Mālama o ke Kai rubrics of Hawaiian values

OBJECTIVE

This study introduces the rubrics of Native Hawaiian values developed to measure youth knowledge and understanding of indigenous values along with 8 other tools to evaluate Hui Mālama o ke Kai (HMK), a culturally relevant, positive youth development, after-school program in a Native Hawaiian community. Findings from our efforts to validate the rubrics tool, as an evaluation measure, using triangulation are presented.

METHODS

Evaluation tools were modified through community input and measured youth risk and protective factors, including knowledge and practice of Hawaiian values. Validity and reliability of the tools were tested by analyzing internal consistency, intraclass correlations, and triangulating data sources.

RESULTS

Corroboration of results from the different data sources indicated convergent validity of measures to evaluate youth understanding and practice of Hawaiian values.

CONCLUSIONS

This community-focused approach to evaluation demonstrates how multiple evaluation instruments may reliably evaluate a program.

Content validity and acceptability of the daily enhancement of meaningful activity program: intervention for mild cognitive impairment patient-spouse dyads

Persons with mild cognitive impairment (PwMCI) are at greater risk for developing Alzheimer disease and experience various difficulties that decrease their quality of life. Very few interventions focus on helping PwMCI improve or maintain functional performance and enhance quality of life through meaningful activity engagement. The purpose of the study was to explore PwMCI and their spouses' perspectives on the content validity, usefulness, and acceptability of the Daily Enhancement of Meaningful Activity (DEMA) program, which included 6 biweekly face-to-face sessions between session assignments and a self-management tool kit of written educational handouts. Nine PwMCI-care partner dyads participated in 3 focus groups (PwMCI alone, spouses alone, and couples) to capture their perspectives on DEMA. The transcribed focus group data were analyzed through content analysis. The three groups provided support for content validity and acceptability of the program, and they suggested additional content areas important to couples experiencing MCI. They also attested to the usefulness of the tool kit and gave suggestions for its further improvement. The findings provide evidence of the content validity and acceptability of the DEMA program. A pilot study to assess feasibility and preliminary efficacy of the DEMA on health-related outcomes is the recommended next research step for this program.

Development assistance for health: donor commitment as a critical success factor

In 1970, led by Canada, the world's richest nations pledged 0.7% of their gross national income (GNI) to official development assistance (ODA). Although this pledge has been renewed several times, with the exception of only five countries, ODA allocations have lagged chronically behind this commitment. Put more bluntly, our rhetoric outpaces our actions. For example, spending only 0.3% GNI on development, Canada performs at about 40% of its pledge. The good news is that development assistance for health has improved over the past two decades, mostly due to private development assistance (PDA) and favourable shifts within bilateral and multilateral funding, but clearly more must be done to enhance this effort. Actions in support of the Millennium Development Goals and the Paris Declaration on Aid Effectiveness should make a difference, subject to monitoring and evaluation, and Canada's Muskoka Initiative also is a step in the right direction. However, while success in meeting international development and global health goals depends on donor and recipient nations working as partners through such mechanisms, the relevance of the developed world as a force for global health will be measured in part by how well its governments keep their development commitments.

A novel self-evaluation tool to assess the team function of a child protection team

OBJECTIVE

The aim of this study was to develop a reliable and valid self-evaluation tool for use by child protection team (CPT) members.

METHODS

An online survey was administered to members of 10 CPTs. The survey included the following 3 sections: 1) initial conditions (eg, team composition, resources), 2) enabling conditions (eg, team effort, strategy), and 3) team effectiveness (eg, team cohesion, meeting performance standards). Each section contained multiple subscales. Internal consistency was calculated using Cronbach α. To evaluate construct validity, the subscale scores of the most advanced teams who qualified as centers of excellence (n = 3) were compared with the subscale scores of the other teams (n = 7) to determine whether the tool could distinguish between the two.

RESULTS

Of 116 team members, 83 (72%) completed the survey. The subscales exhibited good internal consistency (α = .71-.97). The 3 centers of excellence had significantly higher mean scores than the other 7 CPTs on the following subscales: incentives (in the initial conditions section, 61.46 vs 38.89; P = .003), effort (in the enabling conditions section, 79.31 vs 67.70; P = .003), and professional growth (in the team effectiveness section, 83.89 vs 80.40; P = .004).

CONCLUSIONS

This novel survey demonstrates satisfactory test characteristics and can be used to assess CPT performance and identify areas for improvement.

Screening programmes for developmental dysplasia of the hip in newborn infants

BACKGROUND

Uncorrected developmental dysplasia of the hip (DDH) is associated with long term morbidity such as gait abnormalities, chronic pain and degenerative arthritis.

OBJECTIVES

To determine the effect of different screening programmes for DDH on the incidence of late presentation of congenital hip dislocation.

SEARCH STRATEGY

Searches were performed in CENTRAL (The Cochrane Library), MEDLINE and EMBASE (January 2011) supplemented by searches of clinical trial registries, conference proceedings, cross references and contacting expert informants.

SELECTION CRITERIA

Randomised, quasi-randomised or cluster trials comparing the effectiveness of screening programmes for DDH.

DATA COLLECTION AND ANALYSIS

Three independent review authors assessed study eligibility and quality, and extracted data.

MAIN RESULTS

No study examined the effect of screening (clinical and/or ultrasound) and early treatment versus not screening and later treatment.One study reported universal ultrasound compared to clinical examination alone did not result in a significant reduction in late diagnosed DDH or surgery but was associated with a significant increase in treatment.One study reported targeted ultrasound compared to clinical examination alone did not result in a significant reduction in late diagnosed DDH or surgery, with no significant difference in rate of treatment.Meta-analysis of two studies found universal ultrasound compared to targeted ultrasound did not result in a significant reduction in late diagnosed DDH or surgery. There was heterogeneity between studies reporting the effect on treatment rate.Meta-analysis of two studies found delayed ultrasound and targeted splinting compared to immediate splinting of infants with unstable (but not dislocated) hips resulted in no significant difference in the rate of late diagnosed DDH. Both studies reported a significant reduction in treatment with use of delayed ultrasound and targeted splinting.One study reported delayed ultrasound and targeted splinting compared to immediate splinting of infants with mild hip dysplasia on ultrasound resulted in no significant difference in late diagnosed DDH but a significant reduction in treatment. No infants in either group received surgery.

AUTHORS' CONCLUSIONS

There is insufficient evidence to give clear recommendations for practice. There is inconsistent evidence that universal ultrasound results in a significant increase in treatment compared to the use of targeted ultrasound or clinical examination alone. Neither of the ultrasound strategies have been demonstrated to improve clinical outcomes including late diagnosed DDH and surgery. The studies are substantially underpowered to detect significant differences in the uncommon event of late detected DDH or surgery. For infants with unstable hips or mildly dysplastic hips, use of delayed ultrasound and targeted splinting reduces treatment without significantly increasing the rate of late diagnosed DDH or surgery.

Coordination of health behavior counseling in primary care

PURPOSE

We wanted to examine how coordinated care is implemented in primary care practices to address patients' health behavior change needs.

METHODS

Site visit notes, documents, interviews, and online implementation diaries were collected from July 2005 to September 2007 from practice-based research networks (PBRNs) participating in Prescription for Health: Promoting Healthy Behaviors in Primary Care Research Networks (P4H). An iterative group process was used to conduct a cross-case comparative analysis of 9 interventions. Published patient outcomes reports from P4H interventions were referenced to provide information on intervention effectiveness.

RESULTS

In-practice health risk assessment (HRA) and brief counseling, coupled with referral and outreach to a valued and known counseling resource, emerged as the best way to consistently coordinate and encourage follow-through for health behavior counseling. Findings from published P4H outcomes suggest that this approach led to improvement in health behaviors. Automated prompts and decision support tools for HRA, brief counseling and referral, training in brief counseling strategies, and co-location of referral with outreach facilitated implementation. Interventions that attempted to minimize practice or clinician burden through telephone and Web-based counseling systems or by expanding the medical assistant role in coordination of health behavior counseling experienced difficulties in implementation and require more study to determine how to optimize integration in practices.

CONCLUSIONS

Easy-to-use system-level solutions that have point-of-delivery reminders and decision support facilitate coordination of health behavior counseling for primary care patients. Infrastructure is needed if broader integration of health behavior counseling is to be achieved in primary care.

Implementation of collaborative depression management at community-based primary care clinics: an evaluation

OBJECTIVE

This study evaluated a large demonstration project of collaborative care of depression at community health centers by examining the role of clinic site on two measures of quality care (early follow-up and appropriate pharmacotherapy) and on improvement of symptoms (score on Patient Health Questionnaire-9 reduced by 50% or ≤ 5).

METHODS

A quasi-experimental study examined data on the treatment of 2,821 patients aged 18 and older with depression symptoms between 2006 and 2009 at six community health organizations selected in a competitive process to implement a model of collaborative care. The model's key elements were use of a Web-based disease registry to track patients, care management to support primary care providers and offer proactive follow-up of patients, and organized psychiatric consultation.

RESULTS

Across all sites, a plurality of patients achieved meaningful improvement in depression, and in many sites, improvement occurred rapidly. After adjustment for patient characteristics, multivariate logistic regression models revealed significant differences across clinics in the probability of receiving early follow-up (range .34-.88) or appropriate pharmacotherapy (range .27-.69) and in experiencing improvement (.36 to .84). Similarly, after adjustment for patient characteristics, Cox proportional hazards models revealed that time elapsed between first evaluation and the occurrence of improvement differed significantly across clinics (p<.001).

CONCLUSIONS

Despite receiving similar training and resources, organizations exhibited substantial variability in enacting change in clinical care systems, as evidenced by both quality indicators and outcomes. Sites that performed better on quality indicators had better outcomes, and the differences were not attributable to patients' characteristics.

Prevention of alcohol misuse among children, youths and young adults

BACKGROUND

Despite many activities to prevent risky alcohol consumption among adolescents and young adults there is an increase of alcohol intoxications in the group of ten to twenty year old juveniles.

OBJECTIVES

This report gives an overview about the recent literature as well as the German federal prevention system regarding activities concerning behavioral and policy prevention of risky alcohol consumption among children, adolescents and young adults. Furthermore, effective components of prevention activities are identified and the efficiency and efficacy of ongoing prevention programs is evaluated.

METHODS

A systematic literature review is done in 34 databases using Bool'sche combinations of the key words alcohol, prevention, treatment, children, adolescents and young adults.

RESULTS

401 studies were found and 59 studies were selected for the health technology assessment (HTA). Most of the studies are done in USA, nine in Germany. A family strengthening program, personalized computer based intervention at schools, colleges and universities, brief motivational interventions and policy elements like increase of prices and taxes proved effective.

DISCUSSION

Among the 59 studies there are three meta-analyses, 15 reviews, 17 randomized controlled trials (RCT) and 18 cohort studies. Despite the overall high quality of the study design, many of them have methodological weaknesses (missing randomization, missing or too short follow-ups, not clearly defined measurement parameters). The transferability of US-results to the German context is problematic. Only a few prevention activities reach a sustainable reduction of frequency and/or amount of alcohol consumption.

CONCLUSION

The HTA-report shows the need to develop specific and target group focused prevention activities for the German situation. Essential for that is the definition of target goals (reduction of consumption, change of behaviour) as well as the definition and empirical validation of risky alcohol consumption. The efficacy of prevention activities should be proven before they are launched. At present activities for the reduction or prevention of risky alcohol consumption are not sufficiently evaluated in Germany concerning their sustainable efficacy.

Using logic models to capture complexity in systematic reviews

Logic models have long been used to understand complex programs to improve social and health outcomes. They illustrate how a program is designed to achieve its intended outcomes. They also can be used to describe connections between determinants of outcomes, for example, low high-school graduation rates or spiraling obesity rates, thus aiding the development of interventions that target causal factors. However, these models have not often been used in systematic reviews. This paper argues that logic models can be valuable in the systematic review process. First, they can aid in the conceptualization of the review focus and illustrate hypothesized causal links, identify effect mediators or moderators, specify intermediate outcomes and potential harms, and justify a priori subgroup analyses when differential effects are anticipated. Second, logic models can be used to direct the review process more specifically. They can help justify narrowing the scope of a review, identify the most relevant inclusion criteria, guide the literature search, and clarify interpretation of results when drawing policy-relevant conclusions about review findings. We present examples that explain how logic models have been used and how they can be applied at different stages in a systematic review. Copyright © 2011 John Wiley & Sons, Ltd.

Evaluation of a workplace disability prevention intervention in Canada: examining differing perceptions of stakeholders

INTRODUCTION Workplace disability prevention is important, but stakeholders can differ in their appreciation of such interventions. We present a responsive evaluation of a workplace disability prevention intervention in a Canadian healthcare organization. Three groups of stakeholders were included: designers of the intervention, deliverers, and workers. The aim was to examine the appreciation of this intervention by analyzing the discrepancies with respect to what these various stakeholders see as the causes of work disability, what the intervention should aim at to address this problem, and to what extent the intervention works in practice. METHODS A qualitative research method was used, including data-triangulation: (a) documentary materials; (b) semi-structured interviews with the deliverers and workers (n = 14); (c) participatory observations of group meetings (n = 6); (d) member-checking meetings (n = 3); (e) focus-group meetings (n = 2). A grounded theory approach, including some ethnographic methodology, was used for the data-analysis. RESULTS Stakeholders' perceptions of causes for work disability differ, as do preferred strategies for prevention. Designers proposed work-directed measures to change the workplace and work organizations, and individual-directed measures to change workers' behaviour. Deliverers targeted individual-directed measures, however, workers were mostly seeking work-directed measures. To assess how the intervention was working, designers sought a wide range of outcome measures. Deliverers focused on measurable outcomes targeted at reducing work time-loss. Workers perceived that this intervention offered short-term benefits yet fell short in ensuring sustainable return-to-work. CONCLUSION This study provides understanding of where discrepancies between stakeholders' perceptions about interventions come from. Our findings have implications for workplace disability prevention intervention development, implementation and evaluation criteria.

Analysis on teaching evaluation of clinical clerkship at korean medical schools

PURPOSE

The purpose of this study was to investigate the teaching evaluation of clinical clerkship at Korean medical schools, and to suggest a desirable improvement for the clinical teaching evaluation in the future.

METHODS

A questionnaire survey was conducted with a total of 9 multiple-choice questions and 1 essay-type question. The multiple-choice questions were analyzed by the frequency analysis using SPSS 17.0, and the essay-type question was coded by the content analysis.

RESULTS

Survey results were as follows: First, clinical teaching evaluations via online (51.35%) were implemented once a year (94.59%) in most medical schools. Second, the self-made questionnaires by medical school (64.86%) rather than borrowing or adaptation (35.14%) were being used more often as teaching evaluation tool. Third, 37.84% medical schools used the specific form by class type, whereas 62.16% medical schools took the general form regardless of class type. Finally, evaluation tool (n=8), lack of concern and attention to teaching evaluation (n=4), formalities of evaluation (n=4), etc. were exposed as problems of clinical teaching evaluation. With regard to evaluation items, the development of specific questions was required.

CONCLUSION

Teaching evaluation can be used as effective educational tools to improve the clinical clerkship program. To this end, clinical teaching evaluation tools reflecting the characteristics of clinical practice need to be developed.

Outcomes and cost-effectiveness of two nicotine replacement treatment delivery models for a tobacco quitline

Many tobacco cessation quitlines provide nicotine replacement therapy (NRT) in the U.S. but consensus is lacking regarding the best shipping protocol or NRT amounts. We evaluated the impact of the Minnesota QUITPLAN(®) Helpline's shift from distributing NRT using a single eight-week shipment to a two-shipment protocol. For this observational study, the eight week single-shipment cohort (n = 247) received eight weeks of NRT (patches or gum) at once, while the split-shipment cohort (n = 160) received five weeks of NRT (n = 94), followed by an additional three weeks of NRT if callers continued with counseling (n = 66). Patient satisfaction, retention, quit rates, and cost associated with the three groups were compared. A higher proportion of those receiving eight weeks of NRT, whether in one or two shipments, reported that the helpline was "very helpful" (77.2% of the single-shipment group; 81.1% of the two-shipment group) than those receiving five weeks of NRT (57.8% of the one-shipment group) (p = 0.004). Callers in the eight week two-shipment group completed significantly more calls (3.0) than callers in the five week one-shipment group (2.4) or eight week single-shipment group (1.7) (p < 0.001). Using both responder and intent-to-treat calculations, there were no significant differences in 30-day point prevalence abstinence at seven months among the three protocol groups even when controlling for demographic and tobacco use characteristics, and treatment group protocol. The mean cost per caller was greater for the single-shipment phase than the split-shipment phase ($350 vs. $326) due to the savings associated with not sending a second shipment to some participants. Assuming no difference in abstinence rates resulting from the protocol change, cost-per-quit was lowest for the five week one-shipment group ($1,155), and lower for the combined split-shipment cohort ($1,242) than for the single-shipment cohort ($1,350). Results of this evaluation indicate that while satisfaction rates increase among those receiving more counseling and NRT, quit rates do not, even when controlling for demographic and tobacco use characteristics.

Effectiveness of programmes as part of primary prevention demonstrated on the example of cardiovascular diseases and the metabolic syndrome

Background

The HTA-report (HTA = Health Technology Assessment) deals with the primary prevention of cardiovascular diseases and diabetes mellitus type 2. In 2009 approximately 356,000 people died in Germany due to cardiovascular diseases. According to estimations about 6.3 million people are suffering from diabetes mellitus type 2. The interventions that are subsidized by the public health insurance are mainly focused on sufficient physical activities, healthy nutrition, stress management and the reduction of the consumption of addictive drugs and luxury food.

Objectives

Which lifestyle-related measures and/or programmes for primary prevention of cardiovascular diseases and of the metabolic syndrome are effective? To what extent will the health status be improved by these offers? To what extent will existing health resources and skills be strengthened by these offers? Are there any differences regarding the effectiveness among the interventions with respect to different settings or subgroups?

Which lifestyle-related interventions and/or programmes for primary prevention of cardiovascular diseases and of the metabolic syndrome are sustainable and cost-effective? Which outcome parameters are in the view of the contributors decisive for the evaluation of the effectiveness? In the view of the contributor are there different values between the outcome parameters? In the view of the payers and other actors are there different values between the outcome parameters?

Which ethical and juridical factors have to be considered? Which social and/or socio-economic parameters influence the use of the services and effectiveness?

Methods

A systematic literature research is done in 35 databases. For the period 2005 to 2010, reviews, epidemiological and clinical studies as well as economical evaluations which deal with primary prevention programmes regarding cardiovascular diseases or the metabolic syndrome are included.

Results

44 publications meet the inclusion criteria. These studies confirm the effectiveness of the primary prevention programmes. Physical activity programs seem to have a stronger effect than nutrition programmes. Psychological programmes prove as well effectiveness, if they include cognitive behaviour therapy. The identified economical studies indicate that programmes for cardiovascular prevention can be conducted cost-effectively. Interventions that focus on the general population turn out to be particularly cost-effective and sustainable.

Discussion

There is a wide range of primary preventive effective lifestyle-related interventions with high evidence. The outcomes and results are consistent with the recommendations of the two identified evidence-based guidelines regarding the recommendations on lifestyle and healthy nutrition. Furthermore, the cost-effectiveness of primary prevention services is proven. With regard to the economical studies it is however worth noting that this result is based on very few publications. The transferability has to be critically assessed as the studies mainly originate from the American health system.

Conclusion

On the whole a comprehensive setting approach with educative, somatic, psychosocial and activity therapeutic components is recommended. The sustainability of a prevention intervention must be ensured from programme to programme. Long-term studies are necessary to make valid statements regarding the sustainable effectiveness: There is an essential deficit in the current practiced evaluation of the use of primary prevention services provided by the health insurance – mainly regarding the comprehensive setting approach – regarding the evidence-based evaluation of the prescribed preventive interventions. With regard to the ethical, social and economical evaluation the research situation is deficient. The situation has to be particularly analyzed for the socially deprived and one has to respond to their specific needs for prevention.

Developing and testing an evaluation tool to measure clinical teaching

PURPOSE

Teaching evaluation tools can be used to provide feedback to medical educators and help them improve their teaching skills. The purpose of this study was to develop a clinical teaching evaluation tool and test its efficacy.

METHODS

The draft tool was developed based on clinical education literature and was modified by the stakeholder groups. To examine the quality of the instrument, content and construct validity, as well as reliability and fitness were analyzed. Content validity was tested by the stakeholder groups using a survey, and construct validity was verified by confirmatory factor analysis using LISREL 8.8. Internal consistency of items was assessed thorough Cronbach alpha estimation. Rasch analysis using Winstep 3.65 was performed to estimate the fitness of the tool.

RESULTS

The resulting tool consisted of 4 large categories, 25 small categories, and 43 items. According to the test results, the average importance of all 43 items was 4.03 (3.63 to 4.29). Cronbach alpha was 0.9689, and the correlation coefficients between the items were high. With regard to construct validity, 10 items needed minor modifications in the category setting. As the infit (0.76 to 1.23) and outfit (0.75 to 1.40) indices show, 42 items were fit to the item response theory.

CONCLUSION

The clinical teaching evaluation tool that has been developed in this study is valid and reliable and fits the item response theory. It can be used as an evaluation method in a variety of clinical teaching settings.

[Impact of "Seguro Popular" on catastrophic and out-of-pocket health expenditures in rural and urban Mexico, 2005-2008]

OBJECTIVE

To estimate the effect of "Seguro Popular" (SP) on the incidence of catastrophic health expenditure (CHE) and out-of-pocket (OOP) health expenditure in the medium term.

MATERIAL AND METHODS

We used the 'Encuesta de Evaluación del SP' --SP Survey Evaluation-- (2005-2008). We analyzed the SP effect on the rural cohort during two years of follow-up (2006 and 2008) and in the urban cohort during one year of follow-up (2008).

RESULTS

At the local level (regional clusters) we did not find an effect of the SP. At the household level we found a protective effect of SP on CHE and the OOP health payments in outpatient and hospitalization in rural areas; and a significant effect on the reduction of OOP health payments in outpatient services in urban zones.

CONCLUSIONS

SP seems to be an effective program to protect poor household against out-of-pocket health expenditures in the medium term.

Evaluation of community-academic partnership functioning: center for the elimination of hepatitis B health disparities

BACKGROUND

Process evaluation of community-academic partnership function and fidelity to principles of community-based participatory research (CBPR) is essential to achievement of intermediate and long term partnership goals.

OBJECTIVES

This article describes the evaluation of B Free CEED, a community-academic partnership created to address hepatitis health disparities in Asian American and Pacific Islander (API) communities.

METHODS

A mixed methods approach with an online survey and qualitative key informant interviews was conducted with all partnership members at baseline and follow-up, 18 months later.

RESULTS

Survey findings showed stability over time, with some consistent differences in community and academic perspectives. Academic members were somewhat more satisfied with the partnership functioning. Key informant interviews provided contextual data key to further defining partnership functioning.

CONCLUSIONS

Conducting ongoing partnership evaluations is necessary to reassess and align processes and protocols to enhance partnership functioning and strengthen group cohesion.

A national clinician-educator program: a model of an effective community of practice

BACKGROUND

The increasing complexity of medical training often requires faculty members with educational expertise to address issues of curriculum design, instructional methods, assessment, program evaluation, faculty development, and educational scholarship, among others.

DISCUSSION

In 2007, The Royal College of Physicians & Surgeons of Canada responded to this need by establishing the first national clinician-educator program. We define a clinician-educator and describe the development of the program. Adopting a construct from the business community, we use a community of practice framework to describe the benefits (with examples) of this program and challenges in developing it. The benefits of the clinician-educator program include: improved educational problem solving, recognition of educational needs and development of new projects, enhanced personal educational expertise, maintenance of professional satisfaction and retention of group members, a positive influence within the Royal College, and a positive influence within other Canadian academic institutions.

SUMMARY

Our described experience of a social reorganization - a community of practice - suggests that the organizational and educational benefits of a national clinician-educator program are not theoretical, but real.

Improving health outcomes with better patient understanding and education

A central plank of health care reform is an expanded role for educated consumers interacting with responsive health care teams. However, for individuals to realize the benefits of health education also requires a high level of engagement. Population studies have documented a gap between expectations and the actual performance of behaviours related to participation in health care and prevention. Interventions to improve self-care have shown improvements in self-efficacy, patient satisfaction, coping skills, and perceptions of social support. Significant clinical benefits have been seen from trials of self-management or lifestyle interventions across conditions such as diabetes, coronary heart disease, heart failure and rheumatoid arthritis. However, the focus of many studies has been on short-term outcomes rather that long term effects. There is also some evidence that participation in patient education programs is not spread evenly across socio economic groups. This review considers three other issues that may be important in increasing the public health impact of patient education. The first is health literacy, which is the capacity to seek, understand and act on health information. Although health literacy involves an individual's competencies, the health system has a primary responsibility in setting the parameters of the health interaction and the style, content and mode of information. Secondly, much patient education work has focused on factors such as attitudes and beliefs. That small changes in physical environments can have large effects on behavior and can be utilized in self-management and chronic disease research. Choice architecture involves reconfiguring the context or physical environment in a way that makes it more likely that people will choose certain behaviours. Thirdly, better means of evaluating the impact of programs on public health is needed. The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework has been promoted as one such potential approach.

Alternative versus standard packages of antenatal care for low-risk pregnancy

BACKGROUND

The number of visits for antenatal (prenatal) care developed without evidence of how many visits are necessary. The content of each visit also needs evaluation.

OBJECTIVES

To compare the effects of antenatal care programmes with reduced visits for low-risk women with standard care.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2010), reference lists of articles and contacted researchers in the field.

SELECTION CRITERIA

Randomised trials comparing a reduced number of antenatal visits, with or without goal-oriented care, with standard care.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data independently.

MAIN RESULTS

We included seven trials (more than 60,000 women): four in high-income countries with individual randomisation; three in low- and middle-income countries with cluster randomisation (clinics as the unit of randomisation). The number of visits for standard care varied, with fewer visits in low- and middle- income country trials. In studies in high-income countries, women in the reduced visits groups, on average, attended between 8.2 and 12 times. In low- and middle- income country trials, many women in the reduced visits group attended on fewer than five occasions, although in these trials the content as well as the number of visits was changed, so as to be more 'goal oriented'.Perinatal mortality was increased for those randomised to reduced visits rather than standard care, and this difference was borderline for statistical significance (five trials; risk ratio (RR) 1.14; 95% confidence interval (CI) 1.00 to 1.31). In the subgroup analysis, for high-income countries the number of deaths was small (32/5108), and there was no clear difference between the groups (2 trials; RR 0.90; 95% CI 0.45 to 1.80); for low- and middle-income countries perinatal mortality was significantly higher in the reduced visits group (3 trials RR 1.15; 95% CI 1.01 to 1.32). Reduced visits were associated with a reduction in admission to neonatal intensive care that was borderline for significance (RR 0.89; 95% CI 0.79 to 1.02). There were no clear differences between the groups for the other reported clinical outcomes.Women in all settings were less satisfied with the reduced visits schedule and perceived the gap between visits as too long. Reduced visits may be associated with lower costs.

AUTHORS' CONCLUSIONS

In settings with limited resources where the number of visits is already low, reduced visits programmes of antenatal care are associated with an increase in perinatal mortality compared to standard care, although admission to neonatal intensive care may be reduced. Women prefer the standard visits schedule. Where the standard number of visits is low, visits should not be reduced without close monitoring of fetal and neonatal outcome.