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PubMed1997

An experimental comparison of three types of case management for homeless mentally ill persons.

OBJECTIVE: Three types of case management were compared to determine their relative effectiveness in helping people with severe mental illness who were homeless or at risk of homelessness. METHODS: Subjects recruited from a psychiatric emergency room and inpatient units were randomly assigned to one of the three treatment conditions: broker case management, in which the client's needs were assessed, services were purchased from multiple providers, and the client was monitored; assertive community treatment only, in which comprehensive services were provided for an unlimited period; and assertive community treatment augmented by support from community workers, who assisted with activities of daily living and were available for leisure activities. Of 165 subjects recruited, 135 were followed for 18 months. RESULTS: Compared with clients assigned to broker case management, clients assigned to assertive community treatment only and assertive community treatment with community workers had superior outcomes on several variables. They were number of contacts with the assigned treatment program, resource utilization (for example, use of entitlements), severity of thought disorder, activity level, and client satisfaction. Clients in the assertive community treatment only condition achieved more days in stable housing than those in the other two treatment conditions. No significant treatment group effects were found on income, self-esteem, or substance abuse. CONCLUSIONS: Assertive community treatment is superior to broker case management in assisting individuals with serious mental illness who are at risk of homelessness.

Activities of Daily Living↗
PubMed1997

Cost-effectiveness evaluation of three approaches to case management for homeless mentally ill clients.

OBJECTIVE: In this study the authors compared the cost-effectiveness of three approaches to case management for individuals with severe mental illness who were at risk for homelessness: assertive community treatment alone, assertive community treatment with community workers, and brokered case management (purchase of services). METHOD: Individuals were randomly assigned to the three treatment conditions and followed for 18 months. Eligibility requirements included a severe DSM-III axis I diagnosis, such as schizophrenia, and either current homelessness or risk for homelessness based on prior history of homelessness. Participants were recruited from the emergency rooms and inpatient units of local psychiatric hospitals. Data on 85 people were available for analyses: 28 in assertive community treatment alone, 35 in assertive community treatment with community workers, and 22 receiving brokered case management (purchase of services). RESULTS: Clients assigned to the two assertive community treatment conditions had more contact with their treatment programs, experienced greater reductions in psychiatric symptoms, and were more satisfied with their treatment than clients in the brokered condition. There was no statistically significant difference between treatment conditions in terms of the total costs of treating the participants. However, the assertive community treatment conditions spent less money on inpatient services than brokered case management, but more on case management services and maintenance (i.e., food stamps, housing subsidies, and Supplemental Security Income payments). CONCLUSIONS: Assertive community treatment has better client outcomes at no greater cost and is, therefore, more cost-effective than brokered case management.

Adult↗
PubMedDate not supplied

Categories, classes and criteria in childhood disability--experience from a survey in Jamaica.

This paper reports a new classification and criteria for disabilities and handicaps used in a survey of childhood disability in Jamaica. Part of the International Classification of Impairments, Disabilities and Handicaps was used, with an alternative classification for disabilities similar to that of impairment, and with a complete set of criteria for levels of severity. For handicaps, the set proposed in the WHO manual, Training Disabled People in the Community, was used. No difficulties were encountered in the use of definitions or severity criteria. The inter-rater reliability for disability as a whole by community workers was 79% (kappa statistic 0.58), and for the physician and psychologist 90 and 100%. The handicap classification was easy to use but there was some confusion with resulting poor inter-rater reliability for some questions. This could be corrected by clarification of the meaning of the questions during training. We recommend use of this classification and criteria as being simple and realistic for surveys of childhood disability conducted by community workers.

Child↗
PubMed2006

'We don't want to manage poverty': community groups politicise food insecurity and charitable food donations.

Charitable assistance is a common response to food insecurity in many affluent countries. The coalition featured in this case study is explicitly concerned with social justice, mitigating the potential for charitable assistance to mask the extent of food insecurity, its root causes and its long-term consequences. The coalition structure has assisted community workers in transcending day-to-day routines, so as to reflect on the politics of food insecurity and institutionalised responses to this problem. Coalition members have defined food security as an objective whose achievement will entail comprehensive reform. One noteworthy outcome has been to recommend that member groups not redistribute a number of foodstuffs commonly donated by individuals and corporations. In grappling with a tension between responding to immediate needs for food and addressing the root causes of these needs, community workers have paid attention to public health.

Canada↗
PubMed2001

Directly observed therapy for treating tuberculosis.

BACKGROUND: Up to half the people with tuberculosis do not complete their treatment. Strategies to improve adherence to diagnostic and treatment regimens are therefore important. OBJECTIVES: To assess the effects of directly observed therapy by an appointed agent (health worker, community volunteer, or family member) on cure and treatment completion in people on treatment for tuberculosis. SEARCH STRATEGY: We searched The Cochrane Controlled Trials Register, the Cochrane Infectious Diseases Group specialized trials register, MEDLINE, EMBASE, LILACS, and reference lists of articles. We also contacted experts in the field. SELECTION CRITERIA: Randomized and quasi-randomized trials of direct observation of tablet swallowing compared with self treatment for tuberculosis. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. MAIN RESULTS: Four studies (n = 1603 participants) included. There was no difference detected between direct observation and self treatment for cure (Relative Risk [RR] 1.06, 95% confidence interval [CI] 0.98 to 1.14); and for cure plus treatment completion (RR 1.06, 95% CI 1.00 to 1.13). A stratified analysis by the appointed agent (health professional, lay health worker, or family/community member) did not reveal any important differences. One study conducted in an optimal setting in which patients were given a choice of supervisor did show modest benefit: cure (RR 1.13, 95% CI 1.04 to 1.24); cure plus treatment completion (RR 1.11, 95% CI 1.03 to 1.18). REVIEWER'S CONCLUSIONS: Randomized trials provide no evidence that directly observed therapy in low and middle income country settings improves cure or treatment completion rates in patients with tuberculosis.

Antitubercular Agents↗
PubMedDate not supplied

Minority workers and communities.

Environmental and occupational hazards do not affect all communities equally. Members of ethnic and racial minorities, whether as working people or as community residents, sustain disproportionate risks from chemical, physical, and biological hazards. This paper reviews the nature of these disproportionate risks, focusing primarily on the workplace, but considering general environmental exposures as well. It discusses three principal mechanisms of increased risk: excessive hazardous exposures in both the workplace and the general environment, increased susceptibility, and inferior healthcare. It presents evidence that, as the result of these factors, members of minority groups display elevated rates of work-related illness, injury, fatality, and disability. Finally, it offers recommendations with regard to research, primary prevention, minority recruitment into the occupational health professions, and treatment and compensation for injured and ill minority workers.

Career Choice↗
PubMed2001

An exploratory analysis of racial factors in staff burnout among assertive community treatment workers.

We examined racial differences in burnout among case managers working with people with severe mental illness, using the Maslach Burnout Inventory. Compared to Caucasians, African Americans reported significantly less Emotional Exhaustion and Depersonalization, but did not differ on levels of Personal Accomplishment. These differences could not be explained by geographic location or perceptions of the work environment; however, age accounted for group differences in Depersonalization. Racial incongruence with caseload appeared to be one factor in burnout, particularly for Emotional Exhaustion. Race of both staff and clients may be important to consider in understanding staff burnout.

Adult↗
PubMed1987

Malaria chemoprophylaxis to pregnant women provided by community health workers in Saradidi, Kenya. I. Reasons for non-acceptance.

Chloroquine prophylaxis for malaria was available free of charge to pregnant women in Saradidi, Kenya. The drug was supplied by village health helpers (VHH's). However, only 29.1% of 357 pregnant women seen in antenatal clinics from 1983 to 1984 were on chemoprophylaxis. One hundred and seven pregnant women not using antimalarial chemoprophylaxis from 22 villages were interviewed in June 1984 to determine the reasons. Age (mean 26.9 years), parity (mean 4.5 children), occupation (96.3% subsistence farmers and housewives) and education (median five to seven years) of the 107 respondents were similar to other women in the area. Previous pregnancies had occurred in 92 women; for 15 this was the first pregnancy. The last pregnancy had resulted in a live birth for 81 (88.0%), a stillbirth for nine (9.8%) and a miscarriage for two (2.2%); 21 (22.8%) of the 92 had experienced a miscarriage or stillbirth at some time (15 once, five twice and one woman four times). Malaria was the most frequent mentioned (28.6% of 21 women) cause of the last stillbirth or abortion. The major reason for not taking chemoprophylaxis was lack of awareness that the service was available (53.3% of 107 women). Other reasons were fear of chloroquine-induced itching (10.3%), the VHH had no drug (8.4%), the VHH had not advised her to take drug (8.4%), the woman was 'not sick' (7.5%), the woman was 'lazy' (6.5%), she had not been advised by clinic so was afraid to mix medicines (3.7%) and chloroquine was 'bad for pregnancy' (1.9%).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1987

Malaria chemoprophylaxis to pregnant women provided by community health workers in Saradidi, Kenya. III. Serologic studies.

Parasitaemia and antimalarial antibodies were examined from May 1983 to March 1984 in monthly samples taken from 930 pregnant women attending antenatal clinics in Saradidi, Kenya, and 317 of their infants; 104 women were taking chloroquine phosphate 300 mg base weekly for chemoprophylaxis. Seropositivity rates in pregnant women were uniformly high, and mean enzyme-linked immunosorbent assay (ELISA) absorbance values were not related to presence of parasitaemia or history of chemoprophylaxis. Parasitaemia was present in 26.5% of 1677 slides from pregnant women and there was little variation by month of sample. Mean ELISA absorbance values varied by month of sample. Seropositivity rates in infants were high as measured in both the indirect fluorescent antibody (IFA) test (81.6% of 938) and ELISA at 1:100 (83.8% of 1025) and 1:1000 (34.8% of 1025) serum dilutions. Seropositivity rates decreased slightly after birth but by four months of age rates were again high. Parasitaemia was present in 26.5% of 1677 slides from pregnant women. Paired comparisons were made on maternal samples collected less than two months before parturition and samples from the infants collected within two months after birth. The paired antibody response by IFA or ELISA was not dependent on the presence of detectable parasitaemia in the mother. Infants from mothers with a history of antimalarial chemoprophylaxis had significantly (P = 0.04) lower IFA titres than other infants. Measuring the absorbance of a 1:100 serum dilution by ELISA appeared to be an excellent method with which to measure longitudinal serologic changes in a population.

Animals↗
PubMed1987

Malaria chemoprophylaxis to pregnant women provided by community health workers in Saradidi, Kenya. II. Effect on parasitaemia and haemoglobin levels.

To determine the effects of chloroquine phosphate (300 mg base weekly) chemoprophylaxis for malaria provided by volunteer village health helpers (VHH's), pregnant women attending antenatal clinics in Saradidi, Kenya, were examined each month. Parasitaemia, haemoglobin level, and the presence of urinary 4-aminoquinolines were determined at each visit. The age composition and parity of women taking chemoprophylaxis were not statistically significantly different from those of the other women. A total of 104 (29.1%) of 357 pregnant women from 23 villages where chemprophylaxis was provided by VHH's said they were taking it. Women 30 to 44 years of age (43.9%) of 82) were more often taking prophylaxis than those younger (25.1% of 271) (P less than 0.0005). An additional 573 pregnant women to whom regular chemoprophylaxis was not provided from 33 control villages were also examined at least once. When compared with those from women not taking prophylaxis, blood samples from pregnant women on antimalarial prophylaxis had lower parasite rates (17.7% of 265 compared with 26.2% of 1700, P less than 0.005), higher haemoglobin levels (59.1% of 127 were greater than or equal to 10.0 g l-1 compared with 49.7% of 1111, P less than 0.05), and a higher mean haemoglobin level (9.95 g dl-1 compared with 9.62, P = 0.019) and urine samples were more often positive for 4-aminoquinolines (15.7% of 255 compared with 8.3% of 1656, P less than 0.0005). For women with two or more parasitologic samples, 69.6% of 79 pregnant women on prophylaxis had no parasites found on any visit compared with 51.6% of 516 women not on chemoprophylaxis (P less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1996

Community-based ivermectin distributors: onchocerciasis control at the village level in Plateau State, Nigeria.

The use of community residents as agents for distributing mass ivermectin therapy for onchocerciasis provides a component of community participation absent from mobile team delivery methods. Community-based distribution, however, presupposes preexisting human resources in the endemic villages capable of fulfilling the essential functions of an ivermectin distribution process: mobilizing and educating the population, dispensing the drug, maintaining records, and monitoring and treating adverse reactions. Even when such human resources exist, the community workers must continue to receive tangible support from both external (government and donor agencies) and internal (community) sources. Donor and government agencies must accept that their data collection demands will be limited by the literacy standards of the communities being served. Community leaders must agree to set and use their own local standards of payment (including food stuffs or exchange in kind) to compensate the distributors for their time and efforts. The use of locally available human and remunerative resources is a prerequisite for true community ownership of a program.

Antinematodal Agents↗
PubMed1999

Effectiveness of community-directed diabetes prevention and control in a rural Aboriginal population in British Columbia, Canada.

This report presents the process and summative evaluation results from a community-based diabetes prevention and control project implemented in response to the increasing prevalence and impact of non-insulin-dependent diabetes mellitus (NIDDM) in the Canadian Aboriginal population. The 24-month project targeted the registered Indian population in British Columbia's rural Okanagan region. A participatory approach was used to plan strategies by which diabetes could be addressed in ways acceptable and meaningful to the intervention community. The strategies emphasised a combination of changing behaviours and changing environments. The project was quasi-experimental. A single intervention community was matched to two comparison communities. Workers in the intervention community conducted interviews of individuals with or at risk for diabetes during a seven-month pre-intervention phase (n = 59). Qualitative analyses were conducted to yield strategies for intervention. Implementation began in the eighth month of the project. Trend measurements of diabetes risk factors were obtained for 'high-risk' cohorts (persons with or at familial risk for NIDDM) (n = 105). Cohorts were tracked over a 16-month intervention phase, with measurements at baseline, the midpoint and completion of the study. Cross-sectional population surveys of diabetes risk factors were conducted at baseline and the end of the intervention phase (n = 295). Surveys of community systems were conducted three times. The project yielded few changes in quantifiable outcomes. Activation of the intervention community was insufficient to enable individual and collective change through dissemination of quality interventions for diabetes prevention and control. Theory and previous research were not sufficiently integrated with information from pre-intervention interviews. Interacting with these limitations were the short planning and intervention phases, just 8 and 16 months, respectively. The level of penetration of the interventions mounted was too limited to be effective. Attention to process is warranted and to the feasibility of achieving effects within 24 months.

Adult↗
PubMed2001

Shaping the interprofessional agenda: a study examining qualified nurses' perceptions of learning with others.

This paper presents the findings of a survey of post-qualified nursing students undertaking an interprofessional studies programme in a higher education institution. The total population of students surveyed included nurses, midwives, social workers and youth and community workers. However, the findings presented here centre on the data generated from the nurses. The participants made a retrospective evaluation of their educational experiences through focus groups and the use of a semi-structured questionnaire. Out of a potential 36 nurses, 32 (88%) participated in the evaluation. Overall, the nurses appraised their learning positively, although the qualitative data highlighted the complexity of the experience and the importance of skillful facilitation. Learning to work collaboratively entails more than learning about the practical roles of other occupations; it includes an understanding of the knowledge bases, aspirations and values that underpin those roles. The paper contributes to current debates about the most effective ways to prepare nursing students to work interprofessionally. It highlights the importance of evaluating the experiences of those taking part in interprofessional initiatives. This is a distinctive departure from much nursing research in the field in that it gives a voice to participants and identifies how their voice may shape interprofessional policy agendas.

Attitude of Health Personnel↗