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Nutritional interventions through primary health care: impact of the ICDS projects in India.

In 1975 the Government of India initiated an integrated approach for the delivery of health care as well as nutrition and education services for deprived populations at the village level and in urban slums through centres, each of which was run by a local part-time female worker (anganwadi) who was paid an honorarium and had a helper. This national programme, known as the Integrated Child Development Services (ICDS), began with 33 projects but, by March 1986, had expanded to 1611 projects covering 23% of the country's population and representing about 50% of the population in the socioeconomically backward areas. The ICDS can therefore be considered to function as a primary health care programme for preschool children (under 6 years old), pregnant women, and lactating mothers. The present study investigated the impact on the nutritional status of the target population after 3-5 years and after 8 years of ICDS interventions, compared with the nutritional status of non-ICDS (control) groups. The results showed that the ICDS nutrition intervention programmes achieved better coverage of the target population and led to a significant decline in malnutrition among preschool children in the ICDS population, compared with the non-ICDS groups that received nutrition, health care and education through separate programmes. This example may lead other developing countries to introduce integrated programmes with certain modifications to suit local conditions. International agencies and national governments should strive to bring about the integration of nutritional services with primary health care and development programmes for children because of the good results in terms of child survival and child development.

Anthropometry↗

[Translation and content validation of the Childhood Trauma Questionnaire into Portuguese language].

OBJECTIVE: The Childhood Trauma Questionnaire is a self-applied instrument for adolescents and adults to assess childhood abuse. The objective was to translate, adapt and validate the questionnaire content into a Portuguese language version called Questionário sobre Traumas na Infância. METHODS: The translation and adaptation into Portuguese was carried out in five steps: (1) translation; (2) back translation; (3) correction and semantic adaptation; (4) content validation by professional experts (judges); and (5) a final critical assessment by the target population using a verbal rating scale. RESULTS: The translated and adapted 28-item Portuguese version of the scale and instructions produced an instrument called Questionário sobre Traumas na Infância. In the assessment by the target population, 32 adult users of the Brazilian Unified Health System answered the questionnaire and showed good understanding of the instrument (mean=4.86 +/- 0.27) in the verbal rating scale. CONCLUSION: The questionnaire's Portuguese version proved to be easily understandable showing good semantic validation. Nevertheless, further studies should address other psychometric characteristics of this instrument.

Adolescent↗

Factors influencing the return rate in a direct mail campaign to inform minority women about prevention of cervical cancer.

The Forsyth County Cervical Cancer Prevention Project was a 5-year community-based health education program funded by the National Cancer Institute. The program was developed to reduce cervical cancer mortality among black women in Forsyth County, and it was targeted to those ages 18 and older. The program tried to educate the target population through a combination of mass media and direct education. This paper reports on an experiment conducted to investigate sources of influence on the effectiveness of direct mail, a technique used to augment mass media health education. Direct mail has shown promise as a method for reaching target populations that are difficult to reach with other mass media approaches. Using commercially prepared mailing lists sorted by zip code and other characteristics of the resident, health-related materials can be targeted to persons at their homes. A randomized experiment involving 1,000 households was carried out to estimate the influence of type of postage and address (name versus "resident or occupant") on the response rate to direct mail. Results indicated that there was no significant advantage from use of first class over bulk rate postage, but the return was significantly greater when the envelope bore a name rather than "resident or occupant."

Adult↗

Methods of calculating deaths attributable to obesity.

Previously reported estimates of deaths attributable to obesity in the United States have been based on a method that only partially adjusts for confounding and does not allow for effect modification. In this study, the authors investigated the possible magnitude and direction of bias in estimating deaths attributable to obesity when such a method is used. Hypothetical examples are based on 1991 US population data and published relative risks. Incomplete adjustment for confounding of the obesity-mortality relation by age and sex led to a 17% overestimation of deaths due to obesity. Additional bias resulted from slight differences between the derivation cohort and the target population. For example, a difference of three percentage points in the proportion of people 80 years of age or older led to a 42% overestimation of deaths due to obesity. In addition, these estimates appear to be sensitive to minor differences in relative risks between a derivation cohort and the target population. A difference of 0.20 in relative risks almost doubled the number of deaths (97% overestimation). Estimates of deaths attributable to obesity can be biased if confounding and effect modification are not properly taken into account or if the relative risks are not estimated accurately.

Adolescent↗

The effect of screening programmes on the treatment of benign breast neoplasms: observations from current practice in Italy.

PURPOSE: In the Lazio region, Italy, mammographic screening programmes were gradually activated from 1999 to 2003, providing an opportunity to compare two unselected populations in the same time period: women who were contacted in writing, and those who had not been contacted. In this study, we compare the incidences of treatments for benign and malignant neoplasms in the two groups. METHODS: The target population was women aged 50-69 years. We linked all incident cases of surgery for benign and malignant breast neoplasms, from the Hospital Information System (1999-2003) to the Mammographic Screening Information System (1999-2001). We calculated incidence, adjusted for age and standardized breast cancer mortality ratio in each area of residence, for benign and malignant neoplasms surgery in non-yet-contacted and contacted woman. Incidence for contacted women was calculated for the two years following initial contact. RESULTS: The target population in Lazio is 681,000; 116,000 women were contacted during the study period and 3252 malignant and 1566 benign neoplasms were surgically treated. Annual incidence was, respectively, 2.0/1000 and 1.1/1000 for malignant and benign neoplasms in women not contacted, and, respectively, 2.9/1000 and 1.1/1000 in the contacted population. Among the contacted group, annual incidence was 4.3/1000 and 1.5/1000 in compliant women, and 2.0/1000 and 0.9/1000 in non-compliant women. About one-half of the surgeries for benign neoplasms in compliant women were treated against the recommendation of the screening programme. CONCLUSIONS: The implementation of the screening programme did not increase the incidence of treatment for benign neoplasms, and detected 50% more malignant neoplasms.

Aged↗

Impact of dental sick call on combat effectiveness: the Dental Fitness Class 3 soldier.

Dental sick call can have a significant impact on combat effectiveness, a loss of up to 18,720 man days per division per year. This study identified two target populations that interceptive dental treatment could best be directed toward. They are the E-1 to E-3 pay grades and soldiers in combat arms units. This study also offers dental resources needed to treat various target populations.

Adolescent↗

Comparison of health-related quality of life in clinical trial and nonclinical trial human immunodeficiency virus-infected cohorts.

Clinical trials randomly assign treatments and select participants to maximize internal validity, but such selection threatens generalizability by excluding important groups with the diseases under study. Particularly in human immunodeficiency virus (HIV) disease, the results of clinical trials are applied broadly to populations, despite limited representation by minorities and disadvantaged groups. Health-related quality of life (HRQOL), which is increasingly recognized as an important outcome in these studies, may be sensitive to differences that affect generalization of trial results to target populations. This study compared HRQOL in two HIV-infected cohorts: 1) multicenter AIDS Clinical Group Trials in which most subjects are white, privately insured, and high-income (n = 1,907); and 2) a study of ethnically diverse, low-income patients recruited from public clinics (n = 205). Both studies included 30 HRQOL items developed in the Medical Outcomes Study (MOS) and items on symptoms, medications, and demographic characteristics. HRQOL scores were significantly lower in the nontrial sample (P < 0.001) by about one standard deviation, even after direct adjustment for clinical and demographic characteristics, and also after comparison of the nontrial sample with the most symptomatic in the trial sample. The relationships of characteristics with HRQOL differed between nontrial and trial samples, suggesting problems generalizing results from HIV clinical trials to important target populations. HRQOL measures such as those from the MOS can be useful in detecting differences that affect generalization.

Acquired Immunodeficiency Syndrome↗

Patient characteristics determine differences in the influenza vaccination rate more so than practice features.

BACKGROUND: World-wide each year 30-55% of the target population is vaccinated against influenza. Determinants of successful vaccination programs are not clear. This study was aimed at identifying practice- and patient-related factors that determine differences in vaccination rates. METHODS: Data on patients of the target population were extracted from the computerized medical record systems of 48 family practices. Information about organizational factors was collected by a questionnaire for GP's. Multilevel logistic regression analyses were used to assess the determinants. RESULTS: Of all patients at risk (42,426), 76% were vaccinated. The vaccination rate for patients above age 65 was 15% higher when a medical indication was present. Patients with cardiac diseases or diabetes mellitus attained a relatively higher vaccination rate than other groups at risk. Special hours for vaccination led to significantly higher vaccination rates for the elderly and cardiac patients. Patients below 65 years of age were particularly influenced by special information pamphlets. CONCLUSION: Explanations of differences in uptake rates were found at the patient level. All practices in this study were well organized; nevertheless, subgroup analyses showed that special vaccination hours for elderly people and information pamphlets for young people could improve results further.

Adolescent↗

Acceptance of hepatitis B vaccine by workers in a Nigerian teaching hospital.

OBJECTIVES: To determine the pattern of vaccine uptake by hospital personnel in a specifically designed pioneer hepatitis B vaccination programme and to highlight major lessons for ensuring success in future programmes. DESIGN: A review of vaccination and employment records for a forty four-month period and comparative analysis on the basis of professional grouping and work units. SETTING: Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria. SUBJECTS: A total of 2,548 employees of the teaching hospital that have worked for a minimum of one year on a continuous basis between April 1992 and December 1995. INTERVENTIONS: Procurement of recombinant hepatitis B vaccine (Engerix, SmithKline Beecham) by the hospital management and provision of the same to all interested employees of the teaching hospital at no cost under a vaccination programme which was conducted on an on-site basis. MAIN OUTCOME MEASURES: 'Participation' in the vaccination programme was defined as the uptake of at least one dose of hepatitis B vaccine, and 'compliance' defined as the receipt of the three prescribed doses of the hepatitis B vaccine. RESULTS: The level of participation in the vaccination programme was high with 91.9% of the target population of hospital workers receiving at least a dose of the vaccine, while only about half (53.8%) of the group complied with receiving the required three doses of the vaccine. In terms of participation, by professional grouping, laboratory workers and nurses recorded the lowest rates (82.5% and 84% respectively), while 100% participation was recorded in respect of the staff of engineering, medical records, pharmacy and physiotherapy departments. The highest rate of compliance (receipt of three doses) was also found among non-clinical workers (medical record personnel--76.3% and engineering staff--69.5%) while the lowest rate was found among nurses (39.7%) and doctors (40.3%). CONCLUSION: Workers with the highest possibility of knowledge of, and exposure to hepatitis B infection within the hospital setting--doctors, nurses, and laboratory workers--showed the greatest apathy to the vaccination programme. Reasons for this trend demand close examination, and subsequently, identification of specific action that needs to be taken to improve the uptake of the vaccine by the target population, particularly the high-risk groups, in future programmes. Among others, targeting all groups of workers with appropriate education on the infection; active involvement of professional groups in the planning and execution of the vaccination programme; and review of the implementation logistics are some of the key points to note for future programmes.

Hepatitis B↗

Peptic ulcer surgery in the nineties: patient profile, immediate results and clinical findings.

The decreasing frequency of elective ulcer surgery and the persisting frequency of emergency surgery for peptic ulcer diseases has often been reported. The reason for the divergent epidemiological behaviour of the two subgroups of surgical candidates is not clear. The present cross-sectional, population-based analysis of patients undergoing peptic ulcer surgery evaluates the mode of preoperative therapy in elective and emergency cases. It also assesses the present frequency of peptic ulcer surgery, ulcer complications, and the immediate results of ulcer surgery in a target population. The evaluation concerned 117 adult patients (F/M ratio 1/1.1, mean age 58.7 +/- 1.8 years) operated on for peptic ulcer disease in Helsinki City between March 1990 and February 1991. The annual frequency of elective surgery was 8.3 and of emergency surgery 20.7 per 10(5) residents in Helsinki. 30% of the patients treated surgically had no preoperative symptoms or antiulcer medication; the others were on on-demand type H2-receptor antagonist therapy. Whereas there was no mortality from the elective surgery the mortality rate for the emergency surgery was 10%, mainly due to cardiopulmonary reasons among elderly, high-risk patients. In conclusion, since our previous report for 1987 for the same target population in Helsinki, the incidence of emergency surgery has additionally increased, while the incidence of elective surgery has continuously decreased.

Aged↗

The effect of welfare reform on SSA's disability programs: design of policy evaluation and early evidence.

During the past several years, the U.S. social safety net has gone through substantial changes involving an emphasis on personal responsibility and incentives, the shift of certain responsibilities to the states, and new limits on entitlements for benefits. Two pieces of recent legislation affected the Social Security Administration's (SSA's) disability programs. Section 105 of Public Law 104-121, enacted on March 29, 1996, mandated the removal of persons from the Supplemental Security Income (SSI) and Social Security Disability Insurance (DI) rolls for whom drug addiction and alcoholism (DA&A) were material to the determination of disability. It eliminated allowances on the basis of DA&A immediately and required the termination of benefits to all persons receiving benefits at the time of enactment. The other major piece of legislation was the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, which was later amended by the Balanced Budget Act (BBA) of 1997. PRWORA converted the Aid to Families with Dependent Children (AFDC) program from an open-ended entitlement program into a block grant, Temporary Assistance for Needy Families (TANF), incorporating time limits on the receipt of benefits as well as strict work requirements. PRWORA also tightened child eligibility for SSI, narrowed eligibility for noncitizens, and reduced funding for food stamps. The BBA restored SSI eligibility for noncitizens receiving SSI prior to August 1996 and for legal noncitizens residing in the United States prior to August 1996 who become disabled in the future. SSA designed three studies to assess the effects of this legislation. Two of the studies focused on direct effects on SSA's disabled beneficiary population, targeting drug addicts and alcoholics and SSI children. The third study focused on the indirect effects of PRWORA, particularly the replacement of AFDC with TANF, on SSA's programs. The three studies were tied together by a concern of the overall effects--direct or indirect--of the legislative changes on SSA's beneficiary populations and a host of interrelated evaluation issues. The key methodological challenge of these evaluations is the nonexperimental nature of the evidence. The legislative pieces mandating the changes designed to affect SSA's target populations were implemented nationally, without prior demonstration projects. Nonexperimental strategies, such as comparison group designs, must therefore be used to measure the effects of interest. Other challenges relate to the time frames. Since implementing the changes requires a certain amount of time, and outcomes are realized over a period of time after that, the information that can be made available to interested policymakers in the short run is inherently limited to descriptive data on the populations affected and to impressionistic evidence from case studies and process study analyses. The timing problem is particularly acute with respect to measuring the indirect effects of replacing AFDC with TANF, because the most important likely effects will occur over a period of several years, and this time frame may substantially vary across states as a result of the decentralized nature of TANF programs. Finally, the analyses that can be conducted are constrained by the lack of relevant data from existing surveys. Administrative record data alleviate the need for survey information for some purposes, but the lack of survey data still seriously constrains the analyses that can be done in the short term. Because of these methodological challenges, SSA designed an evaluation strategy that uses several methods and data sources, including quantitative analyses of data from surveys and administrative records (particularly data from the Survey of Income and Program Participation, or SIPP, matched to data from administrative records) and qualitative analyses through case studies. (ABSTRACT TRUNCATED)

Alcoholism↗

Organizing public health nursing for the 1990s: generalist or specialist.

Since the 1930s, Public Health Nurses (PHNs) have been deployed in most health units in Canada to provide community-based care for all people living in defined geographical areas. PHNs have provided nursing services for all ages and stages for a variety of health and illness states. A literature review and a systematic analysis of the internal and external factors affecting Public Health Nursing practice in this community led to a recommendation to assign nurses to specific target populations (e.g. parent-child, school, adolescent, adult, seniors) instead of assigning responsibility for all health problems in a geographic location. We describe the processes of assessment, analysis, planning and implementation of the change from geographic assignment to target population assignment for Public Health Nurses.

Canada↗

Possibilities and barriers in the implementation of a preconceptional screening programme for cystic fibrosis carriers: a focus group study.

OBJECTIVE: This qualitative study aimed to explore possibilities and barriers in the implementation of a nationwide preconceptional cystic fibrosis (CF) carrier screening programme. METHODS: Sessions were held with two focus groups of CF patients and CF relatives, one focus group of people from the target population (couples planning a pregnancy), and two focus groups of potential providers (general practitioners (GPs) and municipal health service workers). RESULTS: Important barriers in the implementation of a preconceptional CF carrier screening programme included the problem of reaching the target population, the heavy workload of GPs, the limited public knowledge about CF in general, and the absence of a preconceptional consultation setting. In general, there was a positive attitude among the participants towards CF carrier screening. CONCLUSION: This study revealed some important barriers in the implementation of CF carrier screening programmes. More research is needed to specify and quantify the importance of the various barriers. Eventually, different intervention strategies should be included in an implementation plan to overcome the most important barriers in the organization and execution of screening.

Adult↗

The desirability of involving adolescents in sex education planning.

In summary, several points which indicate the desirability of involving adolescents in sex education planning need to be reiterated. First, without adolescent representation, adults tend to lack an awareness of teenagers' needs for sex information services. The negative consequences of not serving these needs are well-documented. A second important consideration is that without adolescent input there is less chance the sex education programs will be tailored to fit the target population. The data from the Detroit program are useful for making people aware of teenagers' needs for sex education. These data can form a basis for beginning program planning, but they should be strengthened with input from the specific target population the program is intended to serve. And third, getting adolescent health consumers involved in program planning and operation by giving them meaningful responsibility is important to their growth and development. It is hoped increased representation of teenagers in the planning process will improve the quality of sex education programs available to them to the point where the current situation will be reversed so that the majority of sexually active teenagers will not have engaged in intercourse without using contraception because of inaccurate knowledge or difficulty in obtaining birth control. Adolescents must be regarded as people with important things to say and must be included in sex information programs not just as passive receivers, but as active partners in policy formulation and operation.

Adolescent↗

Development of an intervention map for a parent education intervention to prevent violence among Hispanic middle school students.

This paper describes development of Padres Trabajando por la Paz, a violence prevention intervention for Hispanic parents to increase parental monitoring. The intervention was developed using an innovative new program planning process: intervention mapping. Theory and empirical evidence broadly defined performance objectives and determinants of parental monitoring. These objectives were further refined through group and individual interviews with the target parent group. Learning objectives for the intervention guided the content of the intervention that used modeling as the primary method and role model stories as a strategy delivered through newsletters. Stage-matching members of the target population for their readiness to implement the parental monitoring behaviors further refined the social cognitive message design strategies. Intervention mapping provides an explicit theory- and data-driven guide for intervention development that maximizes intervention impact for a specific target population.

Adolescent↗

New techniques for early detection of lung cancer.

The resurgence of interest in lung cancer screening and the application of new techniques for the management of early cancer have raised various issues regarding this global epidemic. In previous randomised clinical trials, the use of conventional chest radiographs and sputum cytology examinations for screening have been shown not to reduce lung cancer mortality. The use of biomolecular markers, autofluorescence bronchoscopy, low-dose spiral and high-resolution computed tomography, endobronchial ultrasonography, optical coherence tomography, confocal micro-endoscopy, positron emission tomography in combination with video-assisted thoracic surgery and intraluminal bronchoscopic treatments may provide new modalities with which to manage lung cancer at the earliest stage possible. New hopes arise that the combined use of more accurate and minimally invasive diagnostic and treatment techniques may justify screening and reduce mortality. More individuals may also benefit, as many in the target population already suffer from poor cardiovascular and pulmonary health due to their smoking history and are considered at risk for surgical intervention. The cost-effectiveness of lung cancer screening will strongly depend on the proper selection of the target population and the optimal application of these new techniques. Despite epidemiological controversy regarding lung cancer screening, the feasibility to define more precisely who are at risk and the use of less invasive techniques may preserve quality of life and improve the survival of many lung cancer patients.

Biomarkers, Tumor↗

Effectiveness of a mass immunization campaign against serogroup C meningococcal disease in Quebec.

CONTEXT: An outbreak of meningococcal disease in Quebec province prompted a mass immunization program. The impact of this campaign on the epidemiology of meningococcal disease has not been studied. OBJECTIVES: To study the impact of a mass immunization campaign using polysaccharide vaccine on the epidemiology of meningococcal disease (MCD) and to assess serogroup C vaccine effectiveness (VE). DESIGN, SETTING, AND SUBJECTS: Analysis of MCD cases reported in Quebec from 1990 to 1998, before and after the mass immunization campaign was conducted during the winter of 1992-1993, when 84% of residents aged 6 months to 20 years (the target population, approximately 1.9 million individuals) were vaccinated. MAIN OUTCOME MEASURES: Incidence of MCD in 1990-1998; incidence of culture-proven serogroup C MCD between April 1, 1993, and March 31, 1998, compared among vaccinated and unvaccinated persons in the target population. RESULTS: The incidence of serogroup C disease decreased after the mass immunization campaign, from 1.4 per 100 000 in 1990-1992 to 0.3 per 100 000 in 1993-1998, and the overall incidence of other serogroups remained stable at 0.7 per 100 000, with a small increase in the proportion of cases caused by serogroup Y (P =.009). Protection from serogroup C MCD was indicated in the first 2 years after vaccine administration (VE, 65%; 95% confidence interval [CI], 20%-84%), but not in the next 3 years (VE, 0%; 95% CI, -5% to 65%). Vaccine effectiveness was strongly related to age at vaccination: 83% (95% CI, 39%-96%) for ages 15 through 20 years, 75% (95% CI, - 17% to 93%) for ages 10 through 14 years, and 41% (95% CI, -106% to 79%) for ages 2 through 9 years. There was no evidence of protection in children younger than 2 years; all 8 MCD cases in this age group occurred in vaccinees. CONCLUSIONS: Serogroup C polysaccharide vaccine is effective for controlling outbreaks in teenaged individuals but should not be used in children younger than 2 years. The mass campaign did not induce significant serogroup switching.

Adolescent↗

Evaluation and comparison of antibody ELISAs for serodiagnosis of bovine trypanosomosis.

A total of 457 serum samples from cattle kept under moderate tsetse challenge in Mukono County, Uganda, (79 of them with confirmed trypanosomosis) and 86 sera from cattle in Germany were tested for Trypanosoma antibodies using enzyme-linked immunosorbent assay (ELISA) with antigen obtained from blood stream form (BSF) and in vitro cultivated procyclic (PRO) trypanosomes. The BSF and PRO ELISA showed a moderate quantitative correlation. A difference plot revealed a slightly non-linear relation between the two methods. Cut-off values were established using (A) non-exposed controls, (B) exposed negative controls and (C) by mixture distribution analysis of the quantitative ELISA results for the sample from the endemic target population. The diagnostic agreement between both assays was significant (kappa, p < 0.05). The diagnostic accuracy of the two tests relative to standard parasitological detection methods was not markedly different as shown by the areas under the receiver operating characteristic (ROC) plots. In our study, neither non-exposed controls (cut-off A) nor exposed negative controls (cut-off B) were suitable for establishing cut-off values. Based on the cut-off value C, derived from mixture distribution analysis, the proportion of animals with elevated antibody levels in the study population was estimated by both assays at 45% (41-50% binomial 95% confidence interval). This can be regarded as an unbiased estimate of the proportion of 'sero-responders' and not necessarily as a proxy for infection prevalence in the target population. We recommend the PRO ELISA to be used for seroepidemiological surveys, since in vitro cultivation of procyclic trypanosomes allows a continuous and standardised preparation of test antigen.

Animals↗