Three-month symptom profiles among symptomatic adults with positive and negative SARS-CoV-2 tests: a prospective cohort study from the INSPIRE group

BACKGROUND

Long-term symptoms following SARS-CoV-2 infection are a major concern, yet their prevalence is poorly understood.

METHODS

We conducted a prospective cohort study comparing adults with SARS-CoV-2 infection (COVID+) with adults who tested negative (COVID-), enrolled within 28 days of an FDA-approved SARS-CoV2 test result for active symptoms. Sociodemographic characteristics, symptoms of SARS-CoV-2 infection (assessed with the CDC Person Under Investigation Symptom List), and symptoms of post-infectious syndromes (i.e., fatigue, sleep quality, muscle/joint pains, unrefreshing sleep, and dizziness/fainting, assessed with CDC Short Symptom Screener for myalgic encephalomyelitis/chronic fatigue syndrome) were assessed at baseline and 3 months via electronic surveys sent via text or email.

RESULTS

Among the first 1,000 participants, 722 were COVID + and 278 were COVID-. Mean age was 41.5 (SD 15.2); 66.3% were female, 13.4% were Black, and 15.3% were Hispanic. At baseline, SARS-CoV-2 symptoms were more common in the COVID + group than the COVID - group. At 3-months, SARS-CoV-2 symptoms declined in both groups although were more prevalent in the COVID + group: upper respiratory symptoms/head/eyes/ears/nose/throat (HEENT; 37.3% vs 20.9%), constitutional (28.8% vs 19.4%), musculoskeletal (19.5% vs 14.7%), pulmonary (17.6% vs 12.2%), cardiovascular (10.0% vs 7.2%), and gastrointestinal (8.7% vs 8.3%); only 50.2% and 73.3% reported no symptoms at all. Symptoms of post-infectious syndromes were similarly prevalent among the COVID + and COVID - groups at 3 months.

CONCLUSIONS

Approximately half of COVID + participants, as compared with one-quarter of COVID - participants, had at least one SARS-CoV-2 symptom at 3 months, highlighting the need for future work to distinguish Long COVID.

Development and testing of data infrastructure in the American College of Emergency Physicians' Clinical Emergency Data Registry for opioid-related research

Objective

Prior research has identified gaps in the capacity of electronic health records (EHRs) to capture the intricacies of opioid-related conditions. We sought to enhance the opioid data infrastructure within the American College of Emergency Physicians' Clinical Emergency Data Registry (CEDR), the largest national emergency medicine registry, through data mapping, validity testing, and feasibility assessment.

Methods

We compared the CEDR data dictionary to opioid common data elements identified through prior environmental scans of publicly available data systems and dictionaries used in national informatics and quality measurement of policy initiatives. Validity and feasibility assessments of CEDR opioid-related data were conducted through the following steps: (1) electronic extraction of CEDR data meeting criteria for an opioid-related emergency care visit, (2) manual chart review assessing the quality of the extracted data, (3) completion of feasibility scorecards, and (4) qualitative interviews with physician reviewers and informatics personnel.

Results

We identified several data gaps in the CEDR data dictionary when compared with prior environmental scans including urine drug testing, opioid medication, and social history data elements. Validity testing demonstrated correct or partially correct data for >90% of most extracted CEDR data elements. Factors affecting validity included lack of standardization, data incorrectness, and poor delimitation between emergency department (ED) versus hospital care. Feasibility testing highlighted low-to-moderate feasibility of date and social history data elements, significant EHR platform variation, and inconsistency in the extraction of common national data standards (eg, Logical Observation Identifiers Names and Codes, International Classification of Diseases, Tenth Revision codes).

Conclusions

We found that high-priority data elements needed for opioid-related research and clinical quality measurement, such as demographics, medications, and diagnoses, are both valid and can be feasibly captured in a national clinical quality registry. Future work should focus on implementing structured data collection tools, such as standardized documentation templates and adhering to data standards within the EHR that would better characterize ED-specific care for opioid use disorder and related research.

Feasibility and acceptability of electronic administration of patient reported outcomes using mHealth platform in emergency department patients with non-medical opioid use

Background

The emergency department (ED) offers an important opportunity to identify patients with opioid use disorder (OUD) and initiate treatment. However, post-ED follow-up is challenging, and novel approaches to enhance care transitions are urgently needed. Outcomes following ED visits have traditionally focused on overdose, treatment engagement, and mortality with an absence of patient reported outcomes (PROs), for example patient ability to schedule follow-up OUD treatment appointments or pick up a prescription medication, that may better inform evaluation of treatment pathways and near-term outcomes after acute events. In the context of increasing novel secure mobile health (mHealth) platforms, we explored the feasibility and acceptability of electronically collecting PROs from ED patients with non-medical opioid use to enhance care in the ED and transitions of care.

Methods

ED patients with non-medical opioid use or opioid overdose who endorsed willingness and ability to complete electronic surveys after discharge were enrolled from a tertiary, urban academic ED. Participants were enrolled in an mHealth platform, shared electronic health records with researchers, and completed electronic surveys of PROs at baseline, three- and thirty-days post discharge from the hospital, including questions about ability to schedule a follow-up appointment, pick up a prescription medication and overdose risk behaviors. Primary outcomes were measures of feasibility and acceptability of electronic PRO collection among ED patients with non-medical opioid use.

Results

Among 1,808 patients assessed for eligibility between June-December 2019, 101 of 130 (78%) eligible adult patients consented to participate. Ninety-six (95%) of 101 patients completed registration in the mHealth platform, and 77/96 (80%) were successful in sharing their electronic health data. Completion rates for the baseline, three-day and thirty-day surveys were 97% (93/96), 49% (47/96) and 42% (40/96). Implementation challenges included short engagement window during ED visit, limited access to smartphones/computers, insufficient battery life of participant phone to access email and password, forgotten emails and passwords, multi-step verification processes for account set-up, and complaints about hospital care, most of which were effectively addressed by study personnel.

Conclusions

ED patients with OUD were willing to share electronic health information and PROs, although implementation challenges were common, and more than half of participants were lost-to-follow-up after hospital discharge at 30 days. Efforts to streamline communication and remove barriers to engagement are needed to improve the collection of PROs and pathways of care in ED patients with OUD.

Clinical Trial Registration ClinicalTrials.gov (NCT03985163). Date of Registration: June 10, 2019, Retrospectively registered (First enrollment June 8, 2019). https://clinicaltrials.gov/ct2/show/record/NCT03985163

Simulating approaches to emergency department pandemic physician staffing during COVID-19

OBJECTIVE

During pandemics, emergency departments (EDs) are challenged by the need to replace quarantined ED staff and avoid staffing EDs with nonemergency medicine (EM) trained physicians. We sought to design and examine three feasible ED staffing models intended to safely schedule EM physicians to staff three EDs within a health system during a prolonged infectious disease outbreak.

METHODS

We conducted simulation analyses examining the strengths and limitations of three ED clinician staffing models: two-team and three-team fixed cohort, and three-team unfixed cohort. Each model was assessed with and without immunity, and by varying infection rates. We assumed a 12-week pandemic disaster requiring a 2-week quarantine.

MAIN OUTCOME

The outcome, time to staffing shortage, was defined as depletion of available physicians in both 8- and 12-hour shift duration scenarios.

RESULTS

All staffing models initially showed linear physician attrition with higher infection rates resulting in faster staffing shortages. The three-team fixed cohort model without immunity was not viable beyond 11 weeks. The three-team unfixed cohort model without immunity avoided staffing shortage for the duration of the pandemic up to an infection rate of 50 percent. The two-team model without immunity also avoided staffing shortage up to 30 percent infection rate. When accounting for immunity, all models behaved similarly initially but returned to adequate staffing during week 5 of the pandemic.

CONCLUSIONS

Simulation analyses reveal fundamental tradeoffs that are critical to designing feasible pandemic disaster staffing models. Emergency physicians should test similar models based on local assumptions and capacity to ensure adequate staffing preparedness for prolonged pandemics.

Fair Play: Application of Normalized Scoring to Emergency Department Throughput Quality Measures in a National Registry

STUDY OBJECTIVE

The measurement of emergency department (ED) throughput as a patient-centered quality measure is ubiquitous; however, marked heterogeneity exists between EDs, complicating comparisons for payment purposes. We evaluate 4 scoring methodologies for accommodating differences in ED visit volume and heterogeneity among ED groups that staff multiple EDs to improve the validity and "fairness" of ED throughput quality measurement in a national registry, with the goal of developing a volume-adjusted throughput measure that balances variation at the ED group level.

METHODS

We conducted an ED group-level analysis using the 2017 American College of Emergency Physicians Clinical Emergency Data Registry data set, which included 548 ED groups inclusive of 889 unique EDs. We calculated ED throughput performance scores for each ED group by using 4 scoring approaches: plurality, simple average, weighted average, and a weighted standardized score. For comparison, ED groups (ie, taxpayer identification numbers) were grouped into 3 types: taxpayer identification numbers with only 1 ED; those with multiple EDs, but no ED with greater than 60,000 visits; and those with multiple EDs and at least 1 ED with greater than 60,000 visits.

RESULTS

We found marked differences in the classification of ED throughput performance between scoring approaches. The weighted standardized score (z score) approach resulted in the least skewed and most uniform distribution across the majority of ED types, with a kurtosis of 12.91 for taxpayer identification numbers composed of 1 ED, 2.58 for those with multiple EDs without any supercenter, and 3.56 for those with multiple EDs with at least 1 supercenter, all lower than comparable scoring methods. The plurality and simple average scoring approaches appeared to disproportionally penalize ED groups that staff a single ED or multiple large-volume EDs.

CONCLUSION

Application of a weighted standardized (z score) approach to ED throughput measurement resulted in a more balanced variation between different ED group types and reduced distortions in the length-of-stay measurement among ED groups staffing high-volume EDs. This approach may be a more accurate and acceptable method of profiling ED group throughput pay-for-performance programs.

Association between patient-physician gender concordance and patient experience scores. Is there gender bias?

BACKGROUND

Patient satisfaction, a commonly measured indicator of quality of care and patient experience, is often used in physician performance reviews and promotion decisions. Patient satisfaction surveys may introduce gender-related bias.

OBJECTIVE

Examine the effect of patient and physician gender concordance on patient satisfaction with emergency care.

METHODS

We performed a cross-sectional analysis of electronic health record and Press Ganey patient satisfaction survey data of adult patients discharged from the emergency department (2015-2018). Logistic regression models were used to examine relationships between physician gender, patient gender, and physician-patient gender dyads. Binary outcomes included: perfect care provider score and perfect overall assessment score.

RESULTS

Female patients returned surveys more often (n=7 612; 61.55%) and accounted for more visits (n=232 024; 55.26%). Female patients had lower odds of perfect scores for provider score and overall assessment score (OR: 0.852, 95% CI: 0.790, 0.918; OR: 0.782, 95% CI: 0.723, 0.846). Female physicians had 1.102 (95% CI: 1.001, 1.213) times the odds of receiving a perfect provider score. Physician gender did not influence male patients' odds of reporting a perfect care provider score (95% CI: 0.916, 1.158) whereas female patients treated by female physicians had 1.146 times the odds (95% CI: 1.019, 1.289) of a perfect provider score.

CONCLUSION

Female patients prefer female emergency physicians but were less satisfied with their physician and emergency department visit overall. Over-representation of female patients on patient satisfaction surveys introduces bias. Patient satisfaction surveys should be deemphasized from physician compensation and promotion decisions.

Assessing the readiness of digital data infrastructure for opioid use disorder research

BACKGROUND

Gaps in electronic health record (EHR) data collection and the paucity of standardized clinical data elements (CDEs) captured from electronic and digital data sources have impeded research efforts aimed at understanding the epidemiology and quality of care for opioid use disorder (OUD). We identified existing CDEs and evaluated their validity and usability, which is required prior to infrastructure implementation within EHRs.

METHODS

We conducted (a) a systematic literature review of publications in Medline, Embase and the Web of Science using a combination of at least one term related to OUD and EHR and (b) an environmental scan of publicly available data systems and dictionaries used in national informatics and quality measurement of policy initiatives. Opioid-related data elements identified within the environmental scan were compared with related data elements contained within nine common health data code systems and each element was graded for alignment with match results categorized as "exact", "partial", or "none."

RESULTS

The literature review identified 5186 articles for title search, of which 75 abstracts were included for review and 38 articles were selected for full-text review. Full-text articles yielded 237 CDEs, only 12 (5.06%) of which were opioid-specific. The environmental scan identified 379 potential data elements and value sets across 9 data systems and libraries, among which only 84 (22%) were opioid-specific. We found substantial variability in the types of clinical data elements with limited overlap and no single data system included CDEs across all major data element types such as substance use disorder, OUD, medication and mental health. Relative to common health data code systems, few data elements had an exact match (< 1%), while 61% had a partial match and 38% had no matches.

CONCLUSIONS

Despite the increasing ubiquity of EHR data standards and national attention placed on the opioid epidemic, we found substantial fragmentation in the design and construction of OUD related CDEs and little OUD specific CDEs in existing data dictionaries, systems and literature. Given the significant gaps in data collection and reporting, future work should leverage existing structured data elements to create standard workflow processes to improve OUD data capture in EHR systems.

National Assessment of Surprise Coverage Gaps Provided to Simulated Patients Seeking Emergency Care

This cross-sectional study evaluates surprise coverage gaps in health insurance by using secret shopper phone call methods to assess whether hospital billing staff in the US are able to answer a set of patient questions about insurance coverage.

Community engagement in public health emergency preparedness

Background

Communities that could be affected by infectious disease outbreaks are increasingly recognised as resources that may be effectively utilized by the authorities during public health emergencies.

Methods

This case study project, aiming to identify synergies between communities and authorities, was based on qualitative sources of evidence, including document and media review, stakeholder mapping, interviews and FGDs (N = 137). Four countries were selected for inclusion: Spain and the Netherlands on the basis of emerging tick-born disease incidents; Iceland and Ireland on the basis of acute gastroenteritis outbreaks.

Results

In the Netherlands and Spain strong synergies were identified in tick surveillance activities, and the value of pre-existing networks of interest groups for preparedness and response activities was recognised. The Icelandic norovirus event was unexpected and fast-moving, while VTEC in Ireland is a familiar and slower-burning challenge. As a relatively common disease in Ireland, VTEC-protocols are closely followed, while a generic all-hazards approach was taken in Iceland. There was considerable community support in the responses in both countries., and in Iceland community representatives also actively participated in producing institutional post-event evaluations.

Conclusions

An over-riding principle emerging from this study is that an informed, at-risk community understands the challenges to adopting effective preventive practices for themselves better than anyone. Additional good practices included the utilisation of pre-existing stakeholder networks for information dissemination; and of monitoring community perceptions of any public health incident, including through social media, in order to identify and manage misperceptions. Efforts to build on the community engagement activities that are already in place in the four countries could contribute to better preparedness planning and more efficient and timely responses in future outbreaks.

Key messages

Recognise the community as a real partner in outbreak preparedness, response, and recovery. Optimise communications with communities who may be affected by outbreaks.

Naloxone Administration Frequency During Emergency Medical Service Events - United States, 2012-2016

As the opioid epidemic in the United States has continued since the early 2000s (1,2), most descriptions have focused on misuse and deaths. Increased cooperation with state and local partners has enabled more rapid and comprehensive surveillance of nonfatal opioid overdoses (3).* Naloxone administrations obtained from emergency medical services (EMS) patient care records have served as a useful proxy for overdose surveillance in individual communities and might be a previously unused data source to describe the opioid epidemic, including fatal and nonfatal events, on a national level (4-6). Using data from the National Emergency Medical Services Information System (NEMSIS),^† the trend in rate of EMS naloxone administration events from 2012 to 2016 was compared with opioid overdose mortality rates from National Vital Statistics System multiple cause-of-death mortality files. During 2012-2016, the rate of EMS naloxone administration events increased 75.1%, from 573.6 to 1004.4 administrations per 100,000 EMS events, mirroring the 79.7% increase in opioid overdose mortality from 7.4 deaths per 100,000 persons to 13.3. A bimodal age distribution of patients receiving naloxone from EMS parallels a similar age distribution of deaths, with persons aged 25-34 years and 45-54 years most affected. However, an accurate estimate of the complete injury burden of the opioid epidemic requires assessing nonfatal overdoses in addition to deaths. Evaluating and monitoring nonfatal overdose events via the novel approach of using EMS data might assist in the development of timely interventions to address the evolving opioid crisis.

Hunger, waiting time and transport costs: Time to confront challenges to ART adherence in Africa

Adherence levels in Africa have been found to be better than those in the US. However around one out of four ART users fail to achieve optimal adherence, risking drug resistance and negative treatment outcomes. A high demand for 2nd line treatments (currently ten times more expensive than 1st line ART) undermines the sustainability of African ART programs. There is an urgent need to identify context-specific constraints to adherence and implement interventions to address them. We used rapid appraisals (involving mainly qualitative methods) to find out why and when people do not adhere to ART in Uganda, Tanzania and Botswana. Multidisciplinary teams of researchers and local health professionals conducted the studies, involving a total of 54 semi-structured interviews with health workers, 73 semi-structured interviews with ARTusers and other key informants, 34 focus group discussions, and 218 exit interviews with ART users. All the facilities studied in Botswana, Tanzania and Uganda provide ARVs free of charge, but ART users report other related costs (e.g. transport expenditures, registration and user fees at the private health facilities, and lost wages due to long waiting times) as main obstacles to optimal adherence. Side effects and hunger in the initial treatment phase are an added concern. We further found that ART users find it hard to take their drugs when they are among people to whom they have not disclosed their HIV status, such as co-workers and friends. The research teams recommend that (i) health care workers inform patients better about adverse effects; (ii) ART programmes provide transport and food support to patients who are too poor to pay; (iii) recurrent costs to users be reduced by providing three-months, rather than the one-month refills once optimal adherence levels have been achieved; and (iv) pharmacists play an important role in this follow-up care.

Revisiting the ABC strategy: HIV prevention in Uganda in the era of antiretroviral therapy

The ABC strategy is credited for bringing the HIV/AIDS epidemic under control in Uganda. By promoting abstinence, being faithful, and condom use, safe(r) behaviours have been identified that are applicable to people in different circumstances. However, scaling-up of antiretroviral therapy in the country raised concerns that HIV prevention messages targeting the uninfected population are not taking sufficient account of inherent complexities. Furthermore, there is debate in the country over relative importance of abstinence in reduction of HIV incidence as well as over the morality and effectiveness of condoms. The purpose of this paper is to examine each component of ABC in light of current developments. It is argued that there is still a strong justification for condom use to complement abstinence and being faithful. There is an urgent need to update and relaunch Uganda's ABC strategy--its three elements are complementary, synergistic, and inseparable in the national HIV prevention programme.

Syndromic management of sexually-transmitted infections and behaviour change interventions on transmission of HIV-1 in rural Uganda: a community randomised trial

BACKGROUND

Treatment of sexually-transmitted infections (STIs) and behavioural interventions are the main methods to prevent HIV in developing countries. We aimed to assess the effect of these interventions on incidence of HIV-1 and other sexually-transmitted infections.

METHODS

We randomly allocated all adults living in 18 communities in rural Uganda to receive behavioural interventions alone (group A), behavioural and STI interventions (group B), or routine government health services and community development activities (group C). The primary outcome was HIV-1 incidence. Secondary outcomes were incidence of herpes simplex virus type 2 (HSV2) and active syphilis and prevalence of gonorrhoea, chlamydia, reported genital ulcers, reported genital discharge, and markers of behavioural change. Analysis was per protocol.

FINDINGS

Compared with group C, the incidence rate ratio of HIV-1 was 0.94 (0.60-1.45, p=0.72) in group A and 1.00 (0.63-1.58, p=0.98) in group B, and the prevalence ratio of use of condoms with last casual partner was 1.12 (95% CI 0.99-1.25) in group A and 1.27 (1.02-1.56) in group B. Incidence of HSV2 was lower in group A than in group C (incidence rate ratio 0.65, 0.53-0.80) and incidence of active syphilis for high rapid plasma reagent test titre and prevalence of gonorrhoea were both lower in group B than in group C (active syphilis incidence rate ratio, 0.52, 0.27-0.98; gonorrhoea prevalence ratio, 0.25, 0.10-0.64).

INTERPRETATION

The interventions we used were insufficient to reduce HIV-1 incidence in rural Uganda, where secular changes are occurring. More effective STI and behavioural interventions need to be developed for HIV control in mature epidemics.

Quantitative process evaluation of a community-based HIV/AIDS behavioural intervention in rural Uganda

This paper describes the implementation of a large community-based HIV/AIDS behavioural intervention in rural Uganda and presents 4 years' worth of quantitative process data. The intervention involved 560 field-based workers (57% male, 76% subsistence farmers, mean age 35 years), supervised by six central staff. Intervention channels included drama and video shows, Community Educators (CEs), as well as leaflet and condom distribution. Activities focused on one or more of 16 key topics. In total, 392 000 attendances (51% female) were recorded--a mean of over 6 for each of the 64 000 target adults--at 81 000 activities, with CEs attracting 71% of the total attendance; 164 000 leaflets and 242 000 condoms were also distributed. The annual cost of the intervention per target individual was approximately US$1.76. Our voluntary workforce experienced an annual attrition rate of 11%, with 'stable' workers more likely to be older, married or opinion leaders in their community than those who dropped out. We calculate that even a significant increase in the proportion of female field workers would have made little difference either to the sex ratio of attendees or to overall attendance. In spite of some initial resistance to the intervention, particularly in relation to condoms, we have demonstrated that people in rural Africa can accept and actively participate in the dissemination of HIV/AIDS prevention messages throughout their own communities.

Policy considerations for using forests to mitigate carbon dioxide emissions

A recent article in Nature, "Soil Fertility Limits Carbon Sequestration by Forest Ecosystems in a CO2-Enriched Atmosphere" by Oren and colleagues, has been widely reported on, and often misinterpreted, by the press. The article dampens enthusiasm for accelerated forest growth due to CO2 fertilization and puts in question the fringe theory that the world"s forests can provide an automatic mitigation feedback. We agree that these results increase our understanding of the global carbon cycle. At the same time, their relevance in the context of the international climate change negotiations is much more complicated than portrayed by newspapers such as the New York Times ("Role of Trees in Curbing Greenhouse Gases is Challenged", May 24, 2001) and the Christian Science Monitor ("Trees No Savior for Global Warming", May 25, 2001).

Condom awareness and intended use: gender and religious contrasts among school pupils in rural Masaka, Uganda

A cross-sectional questionnaire survey examining knowledge, attitudes and intended use of condoms was conducted among 1,821 pupils (mean age = 14.2 years, range = 9--24) from 27 primary and secondary schools in rural south western Uganda. Condom education is not provided in Ugandan schools, but both boys and girls had relatively high overall levels of knowledge, even though boys demonstrated a higher level than girls. This suggests that respondents had successfully obtained reliable information from other sources. Boys and girls had similar and fairly positive attitudes towards condoms, although considerable shyness was expressed, both about discussing condoms with a partner and buying them. Fifty-eight per cent said that they themselves would use a condom if one were available, but girls were far less likely than boys to say so. Roman Catholics (46% of the sample) were less knowledgeable and less positive about condoms than non-Catholics, and the boys in this group, but not the girls, were also much less likely to say they would use one. Possible interventions based on these findings are discussed, and a research agenda for the delivery of assertiveness training to girls is proposed.

The negotiation of sexual relationships among school pupils in south-western Uganda

The objective of the study was to explore how school-going adolescents in south-western Uganda negotiate sexual relationships. Qualitative data were obtained from 15 boys and 15 girls (14-18 years old), during a series of role plays, focus group discussions and one-to-one interviews. A questionnaire was administered to 80 pupils (12-20 years old) from the same school. Most of the pupils were sexually active. Sexual relationships between boys and girls were mediated by peers. Boys initiated relationships. Exchange played an important role in the negotiation of sexual relationships. Money or gifts were given and received in exchange for sexual favours and to strengthen the relationship. To maximize gains, some adolescents had sexual relationships with adults. Sexual relationships were characterized by ambiguity. Love is intertwined with sexual desire, money and prestige. Girls have to be explicit enough to get a good deal; if they are too explicit they will be stigmatized as 'loose' but if they are not interested in money they may be suspected of wanting to spread HIV. Boys try to persuade girls that they have money, but do not want to emphasize this too much. In sexual negotiations a boy must persuade a girl that although he is modern and sophisticated (i.e. experienced) he does not chase after every girl; the girl does not want to come over as an unsophisticated virgin, but does not want to give the impression that she is loose either. There is a tension between the traditional ideal of female chastity and submissiveness and the modern image of sexual freedom. Multiple partnerships were highly valued as a sign of sophistication. Condoms were not considered important. Interventions aimed at reducing the spread of HIV do not seem to be having an effect on the behaviour of this group of adolescents. On the contrary, risky attitudes and behaviour are part of an adolescent ideal of modernity and sophistication. New approaches are needed to persuade this group of the need for change. Shifting the source of interventions from adults to the adolescents themselves, encouraging girls to try other means of earning money and debunking the idea that having many partners is sophisticated may be productive alternatives.

Evaluation of a comprehensive school-based AIDS education programme in rural Masaka, Uganda

A 19 activity extracurricular school-based AIDS education programme lasting 1 year was conducted in rural southwestern Uganda using specially trained teachers, and was evaluated using mutually supportive quantitative and qualitative methods. In total, 1274 students from 20 intervention schools and 803 students from 11 control schools completed questionnaires at baseline, and their classes were followed up. In addition, 93 students from five of the intervention schools participated in 12 focus group discussions. The programme had very little effect--seven of the nine key questionnaire variables showed no significant increase in score after the intervention. Data from the focus group discussions suggest that the programme was incompletely implemented, and that key activities such as condoms and the role-play exercises were covered only very superficially. The main reasons for this were a shortage of classroom time, as well as teachers' fear of controversy and the unfamiliar. We conclude that large-scale comprehensive school-based AIDS education programmes in sub-Saharan Africa may be more completely implemented if they are fully incorporated into national curricula and examined as part of life-skills education. This would require teachers to be trained in participatory teaching methods while still at training college.

Malpractice liability in health professional education

Malpractice lawsuits filed against educators are a relatively new phenomenon. These suits have met with considerable resistance from the courts, which prefer not to involve themselves in assessing the quality of educational services. However, educators in the health professions are more susceptible to legal action because courts are more likely to recognize claims based on medical malpractice. This article reviews the case law regarding negligence as a basis for educational malpractice and suggests ways educators can avoid such litigation.

Implementation of a comprehensive AIDS education programme for schools in Masaka District, Uganda

As part of a large IEC (Information, Education and Communication)/STD intervention trial, a 19-lesson, comprehensive school-based AIDS education programme was implemented and evaluated in 50 primary and 16 secondary schools in 12 parishes of Masaka District, Uganda. A series of three teacher-training and evaluation workshops spread over a year was held in each parish, between which teachers implemented the programme in the classroom. One hundred and forty-eight teachers were trained and about 3,500 students were subsequently exposed to the programme. Both teachers and students responded positively, which suggests that this type of programme has much to offer young people who attend school. However, some problems were encountered: language, programme content, community resistance to teaching about condoms, and several practical issues. Proposed solutions include flexibility with the English language policy, alternative approaches to role play activities, targeting influential individuals with information about the need for young people to learn about safer sex, and a parallel community-based IEC programme to facilitate community acceptance of the need for the programme. In addition, implementation may be incomplete unless comprehensive AIDS education is fully incorporated into the curriculum, and properly examined. These findings are placed in the context of other life skills/AIDS education programmes being introduced both in Uganda and elsewhere in Africa.