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The article looks at the impact of Global Fund financing on health governance and policies in Brazil. It notes the aid of Global Fund financing in the positive transformation of health governance at national-, inter-governmental-, and community levels. It also cites the role of the financing in motivating the National Tuberculosis Programme to strengthen its ties with state and municipal health departments.

The article reports that shiga toxin-producing Escherichia coli (STEC) are the most virulent diarrheagenic E. coli known to date. They can be spread with alarming ease via food as exemplified by a large sprout-borne outbreak of STEC O104:H4 in 2011 that was centered in northern Germany and affected several countries. Effective control of such outbreaks is an important public health task and necessitates early outbreak detection and fast identification of the outbreak.

Background: Invasive meningococcal disease (IMD) caused by serogroup B is the last major serogroup in Canada to become vaccine-preventable. The anticipated availability of vaccines targeting this serogroup prompted an assessment of the epidemiology of serogroup B disease in Ontario, Canada.Methods: We retrieved information on confirmed IMD cases reported to Ontario's reportable disease database between January 1, 2000 and December 31, 2010 and probabilistically-linked these cases to Public Health Ontario Laboratory records. Rates were calculated with denominator data obtained from Statistics Canada. We calculated a crude number needed to vaccinate using the inverse of the infant (<1 year) age-specific incidence multiplied by expected vaccine efficacies between 70% and 80%, and assuming only direct protection (no herd effects).Results: A total of 259 serogroup B IMD cases were identified in Ontario over the 11-year period. Serogroup B was the most common cause of IMD. Incidence ranged from 0.11 to 0.27/100,000/year, and fluctuated over time. Cases ranged in age from 13 days to 101 years; 21.4% occurred in infants, of which 72.7% were <6 months. Infants had the highest incidence (3.70/100,000). Case-fatality ratio was 10.7% overall. If we assume that all infant cases would be preventable by vaccination, we would need to vaccinate between 33,784 and 38,610 infants to prevent one case of disease.Conclusions: Although rare, the proportion of IMD caused by serogroup B has increased and currently causes most IMD in Ontario, with infants having the highest risk of disease. Although serogroup B meningococcal vaccines are highly anticipated, our findings suggest that decisions regarding publicly funding serogroup B meningococcalvaccines will be difficult and may not be based on disease burden alone. [ABSTRACT FROM AUTHOR]

Background: Human brucellosis represents a significant burden to public and veterinary health globally, including the republic of Azerbaijan. The purpose of this study was to examine and describe the spatial and temporal aspects of the epidemiology of human brucellosis in Azerbaijan from 1995 to 2009.Methods: A Geographic information system (GIS) was used to identify potential changes in the spatial and temporal distribution of human brucellosis in Azerbaijan during the study period. Epidemiological information on the age, gender, date, and location of incident cases were obtained from disease registries housed at the Republican Anti-Plague station in Baku. Cumulative incidences per 100,000 populations were calculated at the district level for three, 5-year periods. Spatial and temporal cluster analyses were performed using the Local Moran's I and the Ederer-Myer-Mantel (EMM) test.Results: A total of 7,983 cases of human brucellosis were reported during the 15-year study period. Statisticallysignificant spatial clusters were identified in each of three, five year time periods with cumulative incidence rates ranging from 101.1 (95% CI: 82.8, 124.3) to 203.0 (95% CI; 176.4, 234.8). Spatial clustering was predominant in the west early in the study during period 1 and then in the east during periods 2 and 3. The EMM test identified a greater number of statistically significant temporal clusters in period 1 (1995 to 1999).Conclusion: These results suggest that human brucellosis persisted annually in Azerbaijan across the study period.The current situation necessitates the development of appropriate surveillance aimed at improving control and mitigation strategies in order to help alleviate the current burden of disease on the population. Areas of concern identified as clusters by the spatial-temporal statistical analyses can provide a starting point for implementing targeted intervention efforts. [ABSTRACT FROM AUTHOR]

Background: Enteric fever is a major public health problem, causing an estimated 21million new cases and 216,000or more deaths every year. Current diagnosis of the disease is inadequate. Blood culture only identifies 45 to 70%of the cases and is time-consuming. Serological tests have very low sensitivity and specificity. Clinical samples obtained for diagnosis of enteric fever in the field generally have <1 organism/ml of blood, so that even PCR-based methods, widely used for detection of other infectious diseases, are not a straightforward option in typhoid diagnosis. We developed a novel method to enrich target bacterial DNA by selective removal of human DNA from blood samples, enhancing the sensitivity of PCR tests. This method offers the possibility of improving PCR assays directly using clinical specimens for diagnosis of this globally important infectious disease.Methods: Blood samples were mixed with ox bile for selective lysis of human blood cells and the released human DNA was then digested with addition of bile resistant micrococcal nuclease. The intact Salmonella Typhi bacteriawere collected from the specimen by centrifugation and the DNA extracted with QIAamp DNA mini kit. The presence of Salmonella Typhi bacteria in blood samples was detected by PCR with the fliC-d gene of Salmonella Typhi as the target.Results: Micrococcal nuclease retained activity against human blood DNA in the presence of up to 9% ox bile.Background human DNA was dramatically removed from blood samples through the use of ox bile lysis and micrococcal nuclease for removal of mammalian DNA. Consequently target Salmonella Typhi DNA was enriched in DNA preparations and the PCR sensitivity for detection of Salmonella Typhi in spiked blood samples was enhanced by 1,000 fold.Conclusions: Use of a combination of selective ox-bile blood cell lysis and removal of human DNA with micrococcal nuclease significantly improves PCR sensitivity and offers a better option for improved typhoid PCR assays directly using clinical specimens in diagnosis of this globally important infection disease which we believe could be of importance in improving clinical care and providing effective evaluation of novel vaccines. [ABSTRACT FROM AUTHOR]

Background: Dengue has not reached an endemic status in Taiwan; nevertheless, we have implemented a fever screening program at airports for the early detection of febrile passengers with a dengue infection. This study is intended to assess the performance of the airport screening procedures for dengue infection. Methods: We analyzed data from the national surveillance system of the Taiwan Centers for Disease Control. We included the imported dengue cases reported by sentinel airports and clinics as well as the domestic cases from 2007-2010. Results: Approximately 44.9% (95%CI: 35.73-54.13%) of the confirmed imported dengue cases with an apparent symptom (febrile) in the viremic stage were detected via the airport fever screening program, with an estimated positive predictive value of 2.36% (95% CI: 0.96- 3.75%) and a negative predictive value > 99.99%. Fluctuations in the number of the symptomatic imported dengue cases identified in the airports (X) were associated with the total number of imported dengue cases (Y) based on a regression analysis of a biweekly surveillance (i.e., n = 104, RX2: Y = 0.61, P < 0.005). Additionally, the fluctuating patterns in the cumulative numbers of the imported dengue cases (X) with a 1-2 month lead time (t) was in parallel with that of the domestic dengue cases (Y) based on a consecutive 4-year surveillance (i.e., n = 48, R2 X(t-1):Y = 0.22, R2 X(t-2):Y = 0.31, P < 0.001) from 2007-2010. Conclusions: A moderate sensitivity of detecting dengue at the airports examined in this study indicated some limitations of the fever screening program for the prevention of importation. The screening program could assist in the rapid triage for self-quarantine of some symptomatic dengue cases that were in the viremic stage at the borders and contribute to active sentinel surveillance; however, the blocking of viral transmission to susceptible populations (neighbors or family)... [ABSTRACT FROM AUTHOR]

Background: Eperythrozoonosis is an important animal health problem worldwide, it not only has a major impact on the economic viability, but also makes a significant impact on public health issues. The present systemic review intends to collate all relevant published data to assess the burden of Eperythrozoon infection in Chinese population and discuss the implications of these findings for public health policy. Methods: A meta-analysis was conducted to review the published studies that reported Eperythrozoon spp. in Chinese population. Inclusion criteria comprised of the use of microscopic venous blood smear examination for Eperythrozoon detection and a detailed description of sampling techniques. Results: Twenty-four cross-sectional studies with 52,433 participants and 14,951 positive cases, within the range of China mainland, were included in the present analysis. The infection rate of Eperythrozoon varied from 0 to 97.29% with geographical and seasonal variations, people with mild infection intensity contributed the major part (68.93%). The infection rates were highest in the children and adolescents group, significantly increased risk of Eperythrozoon infection was found among herdsmen. Conclusions: The current study raises awareness about the human eperythrozoonosis in China, which is a newly emerging zoonosis. The majority of Eperythrozoon infection intensity was asymptomatic mild infection. The infection rate of Eperythrozoon in Chinese population varied by geographical region, season, age and occupation. These factors need to be considered when conducting health education campaigns and comparing the surveillance results from different studies. [ABSTRACT FROM AUTHOR]

Recent studies from Austria, France and Italy have shown that there is a poor adherence to the screening scheme for maternal Toxoplasma infections in pregnancy demonstrated by the fact that many recommended examinations are missed. This leads to undetected infections and limits our knowledge of incidence of the disease. We discuss the negative consequences of this situation on research on treatment effectiveness and the outcomes of congenital toxoplasmosis. The responsible public health institutions should assume responsibility for appropriate surveillance of the screening programme and take measures to improve screening adherence during pregnancy. Screening should start as early as possible in pregnancy and the latest test should be done at delivery. Screening schedule should allow distinguishing infections from the first, second and third trimester of pregnancy, as the risk of materno-foetal transmission and outcomes in case of foetal infections varies by time. [ABSTRACT FROM AUTHOR]

Background: Dengue fever has been a major public health concern in China since it re-emerged in Guangdong province in 1978. This study aimed to explore spatiotemporal characteristics of dengue fever cases for both indigenous and imported cases during recent years in Guangdong province, so as to identify high-risk areas of the province and thereby help plan resource allocation for dengue interventions. Methods: Notifiable cases of dengue fever were collected from all 123 counties of Guangdong province from 2005 to 2010. Descriptive temporal and spatial analysis were conducted, including plotting of seasonal distribution of cases, and creating choropleth maps of cumulative incidence by county. The space-time scan statistic was used to determine space-time clusters of dengue fever cases at the county level, and a geographical information system was used to visualize the location of the clusters. Analysis were stratified by imported and indigenous origin. Results: 1658 dengue fever cases were recorded in Guangdong province during the study period, including 94 imported cases and 1564 indigenous cases. Both imported and indigenous cases occurred more frequently in autumn. The areas affected by the indigenous and imported cases presented a geographically expanding trend over the study period. The results showed that the most likely cluster of imported cases (relative risk = 7.52, p<0.001) and indigenous cases (relative risk = 153.56, p<0.001) occurred in the Pearl River Delta Area; while a secondary cluster of indigenous cases occurred in one district of the Chao Shan Area (relative risk = 471.25, p<0.001). Conclusions: This study demonstrated that the geographic range of imported and indigenous dengue fever cases has expanded over recent years, and cases were significantly clustered in two heavily urbanised areas of Guangdong province. This provides the foundation for further investigation of risk factors and interventions in these high-risk areas. [ABSTRACT FROM AUTHOR]

The article presents a study conducted by the authors in which they compared healthcare-associated (HCA)-bloodstream infections (BSI) with community acquired (CA)-BSI and hospital acquired (HA)-BSI. Adults with BSI who were admitted to hospitals in Canada were identified from databases and cases were compared on several basis such as epidemiologic and microbiologic. CA-BSI patients were younger and less likely to have co-morbid medical illnesses as compared to the other two groups.

The article focuses on a study, which aims to evaluate travel-associated health risks and preventative behaviours in a sample of both domestic and international university students in Australia. A 28 item self-administered online survey was distributed to students, that was completed by a total of 1663 respondents. The background, methods, results, and conclusions of the study, are discussed in detail.

The article focuses on a study, which compares the timing, geographic spread and community impact, during the winter wave of influenza pandemic A (H1N1) 2009 to historical influenza seasons, in the World Health Organization (WHO) European region. It was found through routine influenza surveillance data that pandemic influenza had many differential features, when compared to historical seasons in the region. The background, methods, results, and conclusions of the study, are discussed in detail.

Background: The 'overall insecticidal effect' is a key measure used to evaluate public health pesticides for indoor use in experimental hut trials. It depends on the proportion of mosquitoes that are killed out of those that enter the treated hut, intrinsic mortality in the control hut, and the ratio of mosquitoes entering the treatment hut to those entering the control hut. This paper critically examines the way the effect is defined, and discusses how it can be used to infer effectiveness of intervention programmes. Findings: The overall insecticidal effect, as defined by the World Health Organization in 2006, can be negative when deterrence from entering the treated hut is high, even if all mosquitoes that enter are killed, wrongly suggesting that the insecticide enhances mosquito survival. Also in the absence of deterrence, even if the insecticide kills all mosquitoes in the treatment hut, the insecticidal effect is less than 100%, unless intrinsic mortality is nil. A proposed alternative definition for the measurement of the overall insecticidal effect has the desirable range of 0 to 1 (100%), provided mortality among non-repelled mosquitoes in the treated hut is less than the corresponding mortality in the control hut. This definition can be built upon to formulate the coverage-dependent insecticidal effectiveness of an intervention programme. Coverage-dependent population protection against feeding can be formulated similarly. Conclusions: This paper shows that the 2006 recommended quantity for measuring the overall insecticidal effect is problematic, and proposes an alternative quantity with more desirable properties. [ABSTRACT FROM AUTHOR]

Background: Cutaneous Leishmaniasis (CL) is endemic in Sudan. It is caused by Leishmania major parasites and transmitted by Phlebotomus papatasi sandflies. Recently, uncommon clinical manifestations of CL have been reported. Moreover, L. donovani parasites that cause Visceral Leishmaniasis (VL) have been isolated from CL lesions of some patients who contracted the disease in Khartoum State, Central Sudan with no history of travelling to VL endemic sites on south-eastern Sudan. Because different clinical manifestations and the parasite behaviour could be related to genetic differentiation, or even sub-structuring within sandfly vector populations, a population genetic study was conducted on P. papatasi populations collected from different localities in Khartoum State known for their uncommon CL cases and characterized by contrasting environmental conditions. Methods: A set of seven microsatellite loci was used to investigate the population structure of P. papatasi samples collected from different localities in Khartoum State, Central Sudan. Populations from Kassala State, Eastern Sudan and Egypt were also included in the analyses as outgroups. The level of genetic diversity and genetic differentiation among natural populations of P. papatasi was determined using FST statistics and Bayesian assignments. Results: Genetic analyses revealed significant genetic differentiation (FST) between the Sudanese and the Egyptian populations. Within the Sudanese P. papatasi populations, one population from Gerif West, Khartoum State, exhibited significant genetic differentiation from all other populations including those collected as near as 22 km. Conclusion: The significant genetic differentiation of Gerif West P. papatasi population from other Sudanese populations may have important implication for the epidemiology of leishmaniasis in Khartoum State and needs to be further investigated. Primarily, it could be linked to the unique location of Gerif West which is confined by the River Nile and its tributaries that may act as a natural barrier for gene flow between this site and the other rural sites. The observed high migration rates and lack of genetic differentiation among the other P. papatasi populations could be attributed to the continuous human and cattle movement between these localities. [ABSTRACT FROM AUTHOR]

Background: Malaria is a major public health problem in Ghana. We present a site-specific entomological study of malaria vectors and transmission indices as part of an effort to develop a site for the testing of improved control strategies including possible vaccine trials.Methods: Pyrethrum spray catches (PSC), and indoor and outdoor human landing collections of adult female anopheline mosquitoes were carried out over a six-month period (November 2005 - April 2006) at Kpone-on-Sea, a fishing village in southern Ghana. These were morphologically identified to species level and sibling species of the Anopheles gambiae complex further characterized by the polymerase chain reaction (PCR). Enzyme-linked immunosorbent assay was used to detect Plasmodium falciparum mosquito infectivity and host blood meal sources. Parity rate was examined based on dilatation of ovarian tracheoles following dissection. Results: Of the 1233 Anopheles mosquitoes collected, An. gambiae s.l. was predominant (99.5%), followed by An. funestus (0.4%) and An. pharoensis (0.1%). All An. gambiae s.l. examined (480) were identified as An. gambiae s.s. with a majority of M molecular form (98.2%) and only 1.8% S form with no record of M/S hybrid. A significantly higher proportion of anophelines were observed outdoors relative to indoors (?2 = 159.34, df = 1, p < 0.0000). Only An. gambiae M molecular form contributed to transmission with a high degree of anthropophily, parity rate and an estimated entomological inoculation rate (EIR) of 62.1 infective bites/person/year. The Majority of the infective bites occurred outdoors after 09.00 pm reaching peaks between 12.00-01.00 am and 03.00-04.00 am. Conclusion: Anopheles gambiae M molecular form is responsible for maintaining the status quo of malaria in the surveyed site during the study period. The findings provide a baseline for evidence-based planning and implementation of improved malaria interventions. The plasticity observed in biting patterns especially the combined outdoor and early biting behavior of the vector may undermine the success of insecticide-based strategies using insecticide treated nets (ITN) and indoor residual spray (IRS). As such, novel or improved vector interventions should be informed by the local malaria epidemiology data as it relates to vector behavior [ABSTRACT FROM AUTHOR]

Background: Since 2007 Sierra Leone has conducted mass drug administration (MDA) for the elimination of lymphatic filariasis (LF) implemented by unpaid community health volunteers (CHVs). Other health campaigns such as Mother and Child Health Weeks (MCHW) pay for services to be implemented at community level and these persons are then known as community health workers (CHWs). In 2010, the LF MDA in the 12 districts of the Southern, Northern and Eastern Provinces un-expectantly coincided with universal distribution of Long Lasting Insecticide Treated Nets (LLITNs) during the MCHW. In-process monitoring of LF MDA was performed to ensure effective coverage was attained in hard to reach sites (HTR) in both urban and rural locations where vulnerable populations reside. Methods: Independent monitors interviewed individuals eligible for LF MDA and tallied those who recalled having taken ivermectin and albendazole, calculated program coverage and reported results daily by phone. Monitoring of coverage in HTR sites in the 4 most rapidly urbanizing towns was performed after 4 weeks of LF MDA and again after 8 weeks throughout all 12 districts. End process monitoring was performed in randomly selected HTR sites not previously sampled throughout all 12 districts and compared to coverage calculated from the pre-MDA census and reported treatments. Results: Only one town had reached effective program coverage (?80%) after 4 weeks following which CHWs were recruited for LF MDA in all district headquarter towns. After 8 weeks only 4 of 12 districts had reached effective coverage so LF MDA was extended for a further month in all districts. By 12 weeks effective program coverage had been reached in all districts except Port Loko and there was no significant difference between those interviewed in communities versus households or by sex. Effective epidemiological coverage (?65%) was reported in all districts and overall was significantly higher in males versus females. Conclusions: The challenges to LF MDA included the late delivery in country of ivermectin, the availability and motivation of unpaid CHVs, concurrent LLITN distribution and the MCHW, remuneration for CHWs, rapid urbanization and employment seeking population migrations. 'In process' monitoring ensured modifications of LF MDA were made in a timely manner to ensure effective coverage was finally attained even in HTR locations. [ABSTRACT FROM AUTHOR]

Background: Toxoplasma gondii is an intracellular protozoan parasite infecting almost all warm-blooded animals, including birds, with a worldwide distribution. Surveys of T. gondii infection in wild birds have been reported extensively in the world, but little is known of T. gondii infection in peafowls worldwide. This study was performed to determine the seroprevalence of T. gondii infection in peafowls in Yunnan Province, southwestern China. Methods: Sera from 277 peafowls, including 272 blue peafowls (Pavo cristatus) and 5 green peafowls (Pavo muticus) originated from two geographic areas in Yunnan Province were assayed for T. gondii antibodies using the modified agglutination test (MAT). Results: Specific T. gondii antibodies were detected in 35 of 277 (12.64%) peafowls (MAT titer ≥ 1:5). Seropositive birds were found in both species, 33 in 272 blue peafowls and 2 in 5 green peafowls. There was no significant difference in T. gondii seroprevalence between the adolescent birds (6.74%) and the adult birds (6.67%) (P>0.05). The geographical origins of peafowls was found to be highly associated with T. gondii infection in the present study, a statistically significant difference in T. gondii seropositivity was observed between peafowls from Kunming (31.08%) and those from Xishuangbanna Dai Autonomous Prefecture (5.91%) (OR = 10.956, 95% CI = 1.632-73.545, P = 0.014). Statistical analyses showed that there were no significant interactions between ages and geographical origins of peafowls (P > 0.05). Conclusions: The results of the present survey indicated that infection of peafowls with T. gondii is widespread in Yunnan Province, which has significant public health concerns and implications for prevention and control of toxoplamosis in this province. To our knowledge, this is the first seroprevalence report of T. gondii infection in China's southwestern Yunnan Province. [ABSTRACT FROM AUTHOR]

Background: Schistosomiasis remains a major health problem at global and national levels, contributing to the vulnerability of the poor people in Sudan. Southern Kordofan is affected by Schistosomiasis but the disease prevalence was unknown. Methods: 1826 adults were recruited in a community-based survey. Each recruited subject submitted at least 10 ml urine and one stool sample; they were also interviewed and filled in a questionnaire. Results: 1826 adults were recruited in a community-based survey. Each recruited subject submitted at least 10 ml urine and one stool sample; they were also interviewed and filled in a questionnaire. The prevalence of S. haematobium was 6.9 % among the adult population. We estimated S. mansoni prevalence as 0.0 %. S. haematobium infection was focally distributed at the village level. The infection was associated with non preference of latrine use - if available, use of open water source for household affairs such as cleaning and also with the history of schistosomiasis treatment. The prevalence of soil transmitted helminths (STH) was also reported as high at 7.8 %, and two species were identified; Hymenolepis nana and Giardia lamblia. Conclusion: Schistosomiasis is a significant health problem among the adult population in Southern Kordofan. The estimated prevalence will serve as a guide in developing a Schistosomiasis Control Program and applying treatment plans. [ABSTRACT FROM AUTHOR]

Background: Schistosome and soil-transmitted helminth (STH) infections are recognized as major global public health problems, causing severe and subtle morbidity, including significant educational and nutritional effects in children. Although effective and safe drugs are available, ensuring access to these drugs by all those at risk of schistosomiasis and STHs is still a challenge. Community-directed intervention (CDI) has been used successfully for mass distribution of drugs for other diseases such as onchocerciasis and lymphatic filariasis. A national control programme is yet to be instituted in Kenya and evidence for cost-effective strategies for reaching most affected communities is needed. This study evaluated the effectiveness and feasibility of the CDI strategy in the control of schistosomiasis and STHs, in East Uyoma location, Rarieda district, a community of western Kenya that is highly endemic for both infections. Results: Pre-treatment prevalence of S. mansoni averaged 17.4% (range 5-43%) in the entire location. Treatment coverage in different villages ranged from 54.19 to 96.6% by community drug distributor (CDD) records. Assessment from a household survey showed coverage of 52.3 -91.9% while the proportion of homesteads (home compounds) covered ranged from 54.9-98.5%. Six months after one round of drug distribution, the prevalence levels of S. mansoni, hookworm and Trichuris trichura infections were reduced by 33.2%, 69.4% and 42.6% respectively. Conclusions: This study shows that CDI is an accepted and effective strategy in the mass treatment of schistosomiasis and STH infections in resource constrained communities in Kenya and may be useful in similar communities elsewhere. A controlled trial comparing CDI and school based mass drug administration to demonstarte their relative advantages is ongoing [ABSTRACT FROM AUTHOR]

Background: In this study, a total of 426 human faecal samples were examined for the presence of Entamoeba histolytica, Entamoeba dispar, Entamoeba moshkovskii infection via a combination of microscopic examination and nested polymerase chain reaction (PCR) targeting 16S ribosomal RNA of Entamoeba species. Methods: Faecal sample were collected from 426 participants in five rural villages in Peninsular Malaysia. The faecal samples were processed by direct wet smear and formalin ethyl acetate concentration technique followed by iodine staining and examined via microscopy for the presence of Entamoeba species and other intestinal parasites. Microscopically positive samples for Entamoeba species cysts were further characterized using a Nested Polymerase Chain Reaction (Nested-PCR) targeting 16S-like ribosomal RNA gene. The data entry and analysis was carried out using the SPSS software (Statistical Package for the Social Sciences) program for Windows version 17 (SPSS, Chicago, IL, USA). Results: Based on single faecal examination, overall prevalence of Entamoeba infection was 17.6% (75/426). Females (19.1%) were more commonly infected compared to males (15.9%). Comparison by age groups showed that adults (23.9%) had higher infection rates than children (15.3%). The PCR results showed that 52 out of 75 microscopy positive samples successfully generated species-specific amplicons. The infection with E. histolytica (75.0%; 39/52) was the most common, followed by E. dispar (30.8%; 18/52) and E. moshkovskii (5.8%; 3/52). Of these, 33 (63.5%) were shown to contain only E. histolytica, 10 (19.2%) contained E. dispar and 3 (5.8%) contained only E. moshkovskii. Mixed infection with E. histolytica and E. dispar was found in 6 (11.5%) samples.Conclusions: The present study essentially emphasized the benefit of molecular techniques in discriminating the pathogenic Entamoeba species from the non-pathogenic for accurate diagnosis and better management of amoebiasis. The presence of E. moshkovskii is of great public health concern as it was the first time it has been reported in Malaysia. [ABSTRACT FROM AUTHOR]

Background: Malaria is caused by protozoan parasites of the genus Plasmodium. It is one of the leading causes of illness and death in the world. It is a major public health problem in Ethiopia. Over the past years, the disease has been consistently reported as the first leading cause of outpatient visits, hospitalization and death in health facilities across the country. Methods: A retrospective study was conducted to determine the prevalence of malaria from peripheral blood smear examinations from the Kola Diba Health Center of Ethiopia. The case notes of all malaria cases reported between 2002-2011 were carefully reviewed and analyzed. Additionally, any malaria intervention activities that had been taken to control malaria were collected using a well-prepared checklist from the study area. Results: Within the last decade (2002-2011) a total of 59, 208 blood films were requested for malaria diagnosis in Kola Diba health center and 23,473 (39.6%) microscopically confirmed malaria cases were reported in the town with a fluctuating trend. Regarding the identified plasmodium species, Plasmodium falciparum and Plasmodium vivax accounted for 75% and 25% of malaria morbidity, respectively. Malaria was reported in all age groups and both sexes, but the 15-44 year age group and males were more affected. Despite the apparent fluctuation of malaria trends in the area, the highest peak of malaria cases was reported during spring seasons. Conclusion: Comparatively, after the introduction of the current malaria control strategies, the morbidity and mortality by malaria is decreasing but malaria is still a major health problem and the deadly species P. falciparium is predominant. Therefore, control activities should be continued in a strengthened manner in the study area considering both P. falciparium and P. vivax [ABSTRACT FROM AUTHOR]

Abstract: Background: Dermanyssus gallinae (poultry red mite) is a major threat for the poultry industry and is of significant interest for public health. Identification of D. gallinae can be difficult for scientists not familiar with mite morphology and terminology especially when trying to use identification keys. Moreover, this species may easily be confused with another dermanyssoid mite, Ornithonyssus sylviarum (northern fowl mite), which often shares the same hosts and environment. Methods: Specimens of D. gallinae were collected at poultry farms in the Puglia and performed for light and scanning electron microscopy observations, identification and micrographs. Moreover specimens of O. sylviarum were collected separately macerated and mounted on slides for light microscopy observations, identification and pictures. Results: The micrographs used in this study, based on LM and SEM observations, highlight the following important identifying characters of D. gallinae: the prominent shoulders of the dorsal shield and the jagged edges of the shield reticulations, the position of setae j1, s1 and the epigynal pores, and the presence on tibia IV pl of one seta. Additional micrographs highlighting the shape of the dorsal (abruptly narrowed posteriorly) and epigynal (narrowly rounded posteriorly) shields and the chelicera (elongate, with distinct digits) of O. sylviarum enable its differentiation from D.gallinae. Conclusion: The photographic support provided here (both LM and SEM pictures) can be considered a practical tool for scientists who are not well acquainted with the morphology of D.gallinae, and who are involved with classical and molecular systematics, veterinary and human health aspects of poultry red mites [ABSTRACT FROM AUTHOR]

Abstract: Backgound: Treatment of confirmed malaria patients with Artemisinin-based Combination Therapy (ACT) at remote areas is the goal of many anti-malaria programs. Introduction of effective and affordable malaria Rapid Diagnosis Test (RDT) in remote areas could be an alternative tool for malaria case management. This study aimed to assess performance of the OptiMAL dipstick for rapid malaria diagnosis in children under five. Methods: Malaria symptomatic and asymptomatic children were recruited in a passive manner in two community clinics (CCs). Malaria diagnosis by microscopy and RDT were performed. Performance of the tests was determined. Results: RDT showed similar ability (61.2%) to accurately diagnose malaria as microscopy (61.1%). OptiMAL showed a high level of sensitivity and specificity, compared with microscopy, during both transmission seasons (high & low), with a sensitivity of 92.9% vs. 74.9% and a specificity of 77.2% vs. 87.5%. Conclusion: By improving the performance of the test through accurate and continuous quality control of the device in the field, OptiMAL could be suitable for use at CCs for the management and control of malaria. [ABSTRACT FROM AUTHOR]

The article presents a study which aims to estimate the seroprevalence of Toxoplasma (T.) gondii infection in pet dogs in Kunming, Southwest China. The study performs indirect haemagglutination (IHA) using a commercially-marked kit to analyze a total of 611 serum samples for T. gondii antibodies. Results demonstrate high T. gondii seroprevalence in pet dogs that pose a significant public health concern in the area. It suggests enhancing integrated prevention strategies for T. gondii infections in Kunming.

Background: Maps of disease occurrences and GIS-based models of disease transmission risk are increasingly common, and both rely on georeferenced diseases data. Automated methods for georeferencing disease data have been widely studied for developed countries with rich sources of geographic referenced data. However, the transferability of these methods to countries without comparable geographic reference data, particularly when working with historical disease data, has not been as widely studied. Historically, precise geographic information about where individual cases occur has been collected and stored verbally, identifying specific locations using place names. Georeferencing historic data is challenging however, because it is difficult to find appropriate geographic reference data to match the place names to. Here, we assess the degree of care and research invested in converting textual descriptions of disease occurrence locations to numerical grid coordinates (latitude and longitude). Specifically, we develop three datasets from the same, original monkeypox disease occurrence data, with varying levels of care and effort: the first based on an automated web-service, the second improving on the first by reference to additional maps and digital gazetteers, and the third improving still more based on extensive consultation of legacy surveillance records that provided considerable additional information about each case. To illustrate the implications of these seemingly subtle improvements in data quality, we develop ecological niche models and predictive maps of monkeypox transmission risk based on each of the three occurrence data sets. Results: We found macrogeographic variations in ecological niche models depending on the type of georeferencing method used. Less-careful georeferencing identified much smaller areas as having potential for monkeypox transmission in the Sahel region, as well as around the rim of the Congo Basin. These results have implications for mapping efforts, as each higher level of georeferencing precision required considerably greater time investment. Conclusions: The importance of careful georeferencing cannot be overlooked, despite it being a time- and labor-intensive process. Investment in archival storage of primary disease-occurrence data is merited, and improved digital gazetteers are needed to support public health mapping activities, particularly in developing countries, where maps and geographic information may be sparse. [ABSTRACT FROM AUTHOR]

Background: The 'Doctors to the Barrios' (DTTB) Program was launched in 1993 in response to the shortage of doctors in remote communities in the Philippines. While the Program has attracted physicians to work in such areas for the prescribed 2-year period, ongoing monitoring shows that very few chose to remain there for longer and be absorbed by their Local Government Unit (LGU). This assessment was carried out to explore the reasons for the low retention rates and to propose possible strategies to reverse the trend. Methods: A mixed methods approach was used comprising a self-administered questionnaire for members of the current cohort of DTTBs, and oral interviews with former DTTBs. Results: Among former DTTBs, the wish to serve rural populations was the most widely cited motivation. By comparison, among the current cohort of DTTBs, more than half joined the Program due to return of service obligations; a quarter to help rural populations, and some out of an interest in public health. Those who joined the Program to return service experienced significantly less satisfaction, whilst those who joined out of an interest in public health were significantly more satisfied with their rural work. Those who graduated from medical schools in the National Capital Region were significantly more critical about their compensation and perceived there to be fewer options for leisure in rural areas. With regard to the factors impeding retention, lack of support from the LGU was most frequently mentioned, followed by concerns about changes in compensation upon absorption by the LGU, family issues and career advancement. Conclusions: Through improved collaboration with the Department of Health, LGUs need to strengthen the support provided to DTTBs. Priority could be given to those acting out of a desire to help rural populations or having an interest in public health, and those who have trained outside of the National Capital Region. Whether physicians should be able to use the Program to fulfil return service obligations should be critically assessed. [ABSTRACT FROM AUTHOR]

Background: Financial barriers are a recognized major bottleneck of access and use of health services. The aim of this study was to assess effectiveness of a community based health insurance (CBHI) scheme on utilization of health services as well as on mortality and morbidity. Methods: Data were collected from April to December 2007 from the Nouna's Demographic Surveillance System on overall mortality, utilization of health services, household characteristics, distance to health facilities, membership in the Nouna CBHI. We analyzed differentials in overall mortality and selected maternal health process measures between members and non-members of the insurance scheme. Results: After adjusting for covariates there was no significant difference in overall mortality between households who could not have been members (because their area was yet to be covered by the stepped-wedged scheme), non-members but whose households could have been members (areas covered but not enrolled), and members of the insurance scheme. The risk of overall mortality increased significantly with distance to health facility (35% more outside Nouna town) and with education level (37% lower when at least primary school education achieved in households). Conclusion: There was no statistically significant difference in overall mortality between members and nonmembers. The enrolment rates remain low, with selection bias. It is important that community based health insurances, exemptions fees policy and national health insurances be evaluated on prevention of deaths and severe morbidities instead of on drop-out rates, selection bias, adverse selection and catastrophic payments for health care only. Effective social protection will require national health insurance. [ABSTRACT FROM AUTHOR]

Background: Coordinated, interdisciplinary services, supported by self-management underpin effective management for chronic low back pain (CLBP). However, a combination of system, provider and consumer-based barriers exist which limit the implementation of such models into practice, particularly in rural areas where unique access issues exist. In order to improve health service delivery for consumers with CLBP, policymakers and service providers require a more in depth understanding of these issues. The objective of this qualitative study was to explore barriers experienced by consumers in rural settings in Western Australia (WA) to accessing information and services and implementing effective self-management behaviours for CLBP. Methods: Fourteen consumers with a history of CLBP from three rural sites in WA participated. Maximum variation sampling was employed to ensure a range of experiences were captured. An interviewer, blinded to quantitative pain history data, conducted semi-structured telephone interviews using a standardised schedule to explore individuals' access to information and services for CLBP, and self-management behaviours. Interviews were digitally recorded and transcribed verbatim. Inductive analysis techniques were used to derive and refine key themes. Results: Five key themes were identified that affected individuals' experiences of managing CLBP in a rural setting, including: 1) poor access to information and services in rural settings; 2) inadequate knowledge and skills among local practitioners; 3) feelings of isolation and frustration; 4) psychological burden associated with CLBP; and 5) competing lifestyle demands hindering effective self-management for CLBP. Conclusions: Consumers in rural WA experienced difficulties in knowing where to access relevant information for CLBP and expressed frustration with the lack of service delivery options to access interdisciplinary and specialist services for CLBP. Competing lifestyle demands such as work and family commitments were cited as key barriers to adopting regular self-management practices. Consumer expectations for improved health service coordination and a workforce skilled in pain management are relevant to future service planning, particularly in the contexts of workforce capacity, community health services, and enablers to effective service delivery in primary care. [ABSTRACT FROM AUTHOR]

Background: In several northwest European countries, a demand-driven healthcare system has been implemented that stresses the importance of patient healthcare provider choice. In this study, we are conducting a scoping review aiming to map out what is known about the determinants of patient choice of a wide range of healthcare providers. As far as we know, not many studies are currently available that attempt to draw a general picture of how patients choose a healthcare provider and of the status of research on this subject. This study is therefore a valuable contribution to the growing amount of literature about patient choice. Methods: We carried out a specific type of literature review known as a scoping review. Scoping reviews try to examine the breadth of knowledge that is available about a particular topic and therefore do not make selections or apply quality constraints. Firstly, we defined our research questions and searched the literature in Embase, Medline and PubMed. Secondly, we selected the literature, and finally we analysed and summarized the information. Results: Our review shows that patients' choices are determined by a complex interplay between patient and provider characteristics. A variety of patient characteristics determines whether patients make choices, are willing and able to choose, and how they choose. Patients take account of a variety of structural, process and outcome characteristics of providers, differing in the relative importance they attach to these characteristics. Conclusions: There is no such thing as the typical patient: different patients make different choices in different situations. Comparative information seems to have a relatively limited influence on the choices made by many patients and patients base their decisions on a variety of provider characteristics instead of solely on outcome characteristics. The assumptions made in health policy about patient choice may therefore be an oversimplification of reality. Several knowledge gaps were identified that need follow-up research. [ABSTRACT FROM AUTHOR]

Background: Social network analysis is an approach to study the interactions and exchange of resources among people. It can help understanding the underlying structural and behavioral complexities that influence the process of capacity building towards evidence-informed decision making. A social network analysis was conducted to understand if and how the staff of a public health department in Ontario turn to peers to get help incorporating research evidence into practice. Methods: The staff were invited to respond to an online questionnaire inquiring about information seeking behavior, identification of colleague expertise, and friendship status. Three networks were developed based on the 170 participants. Overall shape, key indices, the most central people and brokers, and their characteristics were identified. Results: The network analysis showed a low density and localized information-seeking network. Inter-personal connections were mainly clustered by organizational divisions; and people tended to limit information-seeking connections to a handful of peers in their division. However, recognition of expertise and friendship networks showed more cross-divisional connections. Members of the office of the Medical Officer of Health were located at the heart of the department, bridging across divisions. A small group of professional consultants and middle managers were the most-central staff in the network, also connecting their divisions to the center of the information-seeking network. In each division, there were some locally central staff, mainly practitioners, who connected their neighboring peers; but they were not necessarily connected to other experts or managers. Conclusions: The methods of social network analysis were useful in providing a systems approach to understand how knowledge might flow in an organization. The findings of this study can be used to identify early adopters of knowledge translation interventions, forming Communities of Practice, and potential internal knowledge brokers. [ABSTRACT FROM AUTHOR]

Background: In middle income countries the number of trained health technology assessment specialists is limited and the public budget for health technology assessment is considerably lower compared to developed countries. These countries therefore must develop their own solutions to improve the quality and efficiency of health technology assessment implementation in reimbursement decisions. Our study aimed to develop a scientifically rigorous and detailed appraisal checklist for economic evaluations of pharmaceuticals in the single health technology assessment process. Methods: The research design entailed a review of economic evaluations, submitted for reimbursement of pharmaceuticals, by two independent academic reviewers to identify the most common methodological problems. Fifty economic evaluations submitted in 2007-2008, randomly selected by the Health Technology Assessment Office served as data sources. The new checklist was developed by an iterative working process: first by assessing ten economic evaluations, then improving the checklist by generating new question items, then employing the improved checklist to assess the next ten economic evaluations. After appraising 25 documents, the reviewers reconciled their opinions and improved the checklist with the researchers of the Health Technology Assessment Office during an expert panel discussion. The reviewers scrutinized the second 25 economic evaluations, after which the expert panel finalized the checklist with consensus. Results: The final checklist consists of 91 yes or no questions in 11 main topics concerning comparator selection, efficacy, effectiveness, costs, sensitivity analysis, methodological approach, transparency, and interpretation of results. The new checklist is based on current Hungarian evaluation practice. As the published checklist will be part of the official single health technology assessment process of pharmaceuticals, submitters will be able to assure the quality of their economic evaluation. Conclusions: The transparent critical appraisal method should improve the consistency of pharmaceutical reimbursement decisions and facilitate the utilization of economic evaluations in other fields of health care decision-making in other Central-Eastern European countries. [ABSTRACT FROM AUTHOR]

Background: Road traffic injuries (RTI) are an increasing public health problem in India where out-of-pocket (OOP) expenditures on health are among the highest in the world. We estimated the OOP expenses for RTI in a large city in India. Methods: Information on medical and non-medical expenditure was documented for RTI cases of all ages that reported alive or dead to the emergency departments of two public hospitals and a large private hospital in Hyderabad. Differential risk of catastrophic OOP total expenditure (COPE-T) and medical expenditure (COPE-M), and distress financing was assessed for 723 RTI cases that arrived alive at the study hospitals with multiple logistic regression. Catastrophic expenditure was defined as expenditure > 25% of the RTI patient's annual household income. Variation in intensity of COPE-M in RTI was assessed using multiple classification analysis (MCA). Results: The median OOP medical and non-medical expenditure was USD 169 and USD 163, respectively. The prevalence of COPE-M and COPE-T was 21.9% (95% CI 18.8-24.9) and 46% (95% CI 42-49.3), respectively. Only 22% had access to medical insurance. Being admitted to a private hospital (OR 5.2, 95% CI 2.7-9.9) and not having access to insurance (OR 3.8, 95% CI 1.9-7.6) were significantly associated with risk of having COPE - M. Similar results were seen for COPE - T. MCA analysis showed that the burden of OOP medical expenditure was mainly associated with in-patient days in hospital (Eta =0.191). Prevalence of distress financing was 69% (95% CI 65.5-72.3) with it being significantly higher for those reporting to the public hospitals (OR 2.8, 95% CI 1.7-4.6), those belonging to the lowest per capita annual household income quartile (OR 7.0, 95% CI 3.7-13.3), and for those without insurance access (OR 3.4, 95% CI 2.0-5.7). Conclusions: This paper has outlined the high burden of out-of-pocket medical and total expenditure associated with RTI in India. These data reinforce the need for implementing more effective financial protection mechanisms in India against the high out-of-pocket expenditure incurred on RTI. [ABSTRACT FROM AUTHOR]

Background: Patient safety is fundamental in high quality healthcare systems but despite an excellent record of perinatal care in Sweden some children still suffer from substandard care and unnecessary birth injuries. Sustainable patient safety improvements assume changes in key actors' mental models, norms and culture as well as in the tools, design and organisation of work. Interventions positively affecting team mental models on safety issues are a first step to enhancing change. Our purpose was to study a national intervention programme for the prevention of birth injuries with the aim to elucidate how the main interventions of self-assessment, peer review, feedback and written agreement for change affected the teams and their mental model of patient safety, and thereby their readiness for change. Knowledge of relevant considerations before implementing this type of patient safety intervention series could thereby be increased. Methods: Eighty participants in twenty-seven maternity units were interviewed after the first intervention sequence of the programme. A content analysis using a priori coding was performed in order to relate results to the anticipated outcomes of three basic interventions: self-assessment, peer review and written feedback, and agreement for change. Results: The self-assessment procedure was valuable and served as a useful tool for elucidating strengths and weaknesses and identifying areas for improvement for a safer delivery in maternity units. The peer-review intervention was appreciated, despite it being of less value when considering the contribution to explicit outcome effects (i.e. new input to team mental models and new suggestions for actions). The feedback report and the mutual agreement on measures for improvements reached when signing the contract seemed exert positive pressures for change. Conclusions: Our findings are in line with several studies stressing the importance of self-evaluation by encouraging a thorough review of objectives, practices and outcomes for the continuous improvement of an organisation. Even though effects of the peer review were limited, feedback from peers, or other change agents involved, and the support that a clear and well-structured action plan can provide are considered to be two important complements to future self-assessment procedures related to patient safety improvement. [ABSTRACT FROM AUTHOR]

Background: The role of Community Health Workers (CHWs) in improving access to basic healthcare services, and mobilising community actions on health is broadly recognised. The Primary Health Care (PHC) approach, identified in the Alma Ata conference in 1978, stressed the role of CHWs in addressing community health needs. Training of CHWs is one of the key aspects that generally seeks to develop new knowledge and skills related to specific tasks and to increase CHWs' capacity to communicate with and serve local people. This study aimed to analyse the CHW training process in Iran and how different components of training have impacted on CHW performance and satisfaction. Methods: Data were collected from both primary and secondary sources. Training policies were reviewed using available policy documents, training materials and other relevant documents at national and provincial levels. Documentary analysis was supplemented by individual interviews with ninety-one Iranian CHWs from 18 provinces representing a broad range of age, work experience and educational levels, both male and female. Results: Recognition of the CHW program and their training in the national health planning and financing facilitates the implementation and sustainability of the program. The existence of specialised training centres managed by district health network provides an appropriate training environment that delivers comprehensive training and increases CHWs' knowledge, skills and motivation to serve local communities. Changes in training content over time reflect an increasing number of programs integrated into PHC, complicating the work expected of CHWs. In-service training courses need to address better local needs. Conclusion: Although CHW programs vary by country and context, the CHW training program in Iran offers transferable lessons for countries intending to improve training as one of the key elements in their CHW program. [ABSTRACT FROM AUTHOR]

Background: Patients' experiences have become central to assessing the performance of healthcare systems worldwide and are increasingly being used to inform quality improvement processes. This paper explores the relative value of surveys and detailed patient narratives in identifying priorities for improving breast cancer services as part of a quality improvement process. Methods: One dataset was collected using a narrative interview approach, (n = 13) and the other using a postal survey (n = 82). Datasets were analyzed separately and then compared to determine whether similar priorities for improving patient experiences were identified. Results: There were both similarities and differences in the improvement priorities arising from each approach. Day surgery was specifically identified as a priority in the narrative dataset but included in the survey recommendations only as part of a broader priority around improving inpatient experience. Both datasets identified appointment systems, patients spending enough time with staff, information about treatment and side effects and more information at the end of treatment as priorities. The specific priorities identified by the narrative interviews commonly related to 'relational' aspects of patient experience. Those identified by the survey typically related to more 'functional' aspects and were not always sufficiently detailed to identify specific improvement actions. Conclusions: Our analysis suggests that whilst local survey data may act as a screening tool to identify potential problems within the breast cancer service, they do not always provide sufficient detail of what to do to improve that service. These findings may have wider applicability in other services. We recommend using an initial preliminary survey, with better use of survey open comments, followed by an in-depth qualitative analysis to help deliver improvements to relational and functional aspects of patient experience. [ABSTRACT FROM AUTHOR]

Background: Educational attainment is strongly related to specific health outcomes. The pathway in which individual patient-provider interactions contribute to (re)producing these inequalities has yet to be studied. In this article, the focus is on differences between less and more highly educated patients in their preferences for and experiences with patient-centred care., e.g. shared decision making, receiving understandable explanations and being able to ask questions. Methods: Data are derived from several Consumer Quality-index (CQ-index) studies. The CQ-index is a family of standardized instruments which are used in the Netherlands to measure quality of care from the patient's perspective. Results: The educational level of patients is directly related to the degree of importance patients attribute to specific aspects of patient-centred care. It has a minor influence on the experienced level of shared decision making, but not on experiences regarding other aspects of patient-centred care. Conclusions: All patients regard patient-centred care as important and report positive experiences. However, there is a discrepancy between patient preferences for patient-centred care on one hand and the care received on the other. Less educated patients might receive 'too much', and more highly educated patients 'too little' in the domains of communication, information and shared decision making. [ABSTRACT FROM AUTHOR]

Background: Fatigue is common and has been shown to result in high economic costs to society. The aim of this study is to compare the cost-effectiveness of two active therapies, graded-exercise (GET) and counselling (COUN) with usual care plus a self-help booklet (BUC) for people presenting with chronic fatigue. Methods: A randomised controlled trial was conducted with participants consulting for fatigue of over three months' duration recruited from 31 general practices in South East England and allocated to one of three arms. Outcomes and use of services were assessed at 6-month follow-up. The main outcome measure used in the economic evaluation was clinically significant improvements in fatigue, measured using the Chalder fatigue scale. Cost-effectiveness was assessed using the net-benefit approach and cost-effectiveness acceptability curves. Results: Full economic and outcome data at six months were available for 163 participants; GET = 51, COUN = 58 and BUC = 54. Those receiving the active therapies (GET and COUN) had more contacts with care professionals and therefore higher costs, these differences being statistically significant. COUN was more expensive and less effective than the other two therapies. The incremental cost-effectiveness ratio of GET compared to BUC was equal to £987 per unit of clinically significant improvement. However, there was much uncertainty around this result.Conclusion: This study does not provide a clear recommendation about which therapeutic option to adopt, based on efficiency, for patients with chronic fatigue. It suggests that COUN is not cost-effective, but it is unclear whether GET represents value for money compared to BUC. [ABSTRACT FROM AUTHOR]

Background: The model of volunteer community health workers (CHWs) is a common approach to serving the poor communities in developing countries. BRAC, a large NGO in Bangladesh, is a pioneer in this area, has been using female CHWs as core workers in its community-based health programs since 1977. After 25 years of implementing of the CHW model in rural areas, BRAC has begun using female CHWs in urban slums through a community-based maternal health intervention. However, BRAC experiences high dropout rates among CHWs suggesting a need to better understand the impact of their dropout which would help to reduce dropout and increase program sustainability. The main objective of the study was to estimate impact of dropout of volunteer CHWs from both BRAC and community perspectives. Also, we estimated cost of possible strategies to reduce dropout and compared whether these costs were more or less than the costs borne by BRAC and the community. Methods: We used the 'ingredient approach' to estimate the cost of recruiting and training of CHWs and the so-called 'friction cost approach' to estimate the cost of replacement of CHWs after adapting. Finally, we estimated forgone services in the community due to CHW dropout applying the concept of the friction period. Results: In 2009, average cost per regular CHW was US$ 59.28 which was US$ 60.04 for an ad-hoc CHW if a CHW participated a three-week basic training, a one-day refresher training, one incentive day and worked for a month in the community after recruitment. One month absence of a CHW with standard performance in the community meant substantial forgone health services like health education, antenatal visits, deliveries, referrals of complicated cases, and distribution of drugs and health commodities. However, with an additional investment of US$ 121 yearly per CHW BRAC could save another US$ 60 invested for an ad-hoc CHW plus forgone services in the community. Conclusion: Although CHWs work as volunteers in Dhaka urban slums impact of their dropout is immense both in financial term and forgone services. High cost of dropout makes the program less sustainable. However, simple and financially competitive strategies can improve the sustainability of the program. [ABSTRACT FROM AUTHOR]

Background: Little is known about service providers' knowledge, attitudes, and experiences in relation to the assessment, diagnosis, and treatment of individuals seeking care for sexually transmitted infections (STIs), and how they influence the delivery of services. The purpose of this study was to explore the perceptions of STI care providers and the ways they approached their practice. Methods: We used a qualitative approach drawing on methods used in thematic analysis. Individual semistructured in-depth interviews were conducted with 21 service providers delivering STI services in youth clinics, STI clinics, reproductive health clinics, and community public health units in British Columbia (BC), Canada. Results: Service providers' descriptions of their activities and roles were shaped by a number of themes including specialization, scarcity, and maintaining the status quo. The analysis suggests that service providers perceive, at times, the delivery of STI care to be inefficient and inadequate. Conclusion: Findings from this study identify deficits in the delivery of STI services in BC. To understand these deficits, more research is needed to examine the larger health care structure within which service providers work,and how this structure not only informs and influences the delivery of services, but also how particular structural barriers impinge on and/or restrict practice. [ABSTRACT FROM AUTHOR]

Background: The extant literature suggests that poorly defined job roles make it difficult for peer support workers to be successful, and hinder their integration into multi-disciplinary workplace teams. This article uses data gathered as part of a participatory evaluation of a peer support program at a psychiatric tertiary care facility to specify the work that peers do. Methods: Data were gathered through interviews, focus groups, and activity logs and were analyzed using a modified grounded theory approach. Results: Peers engage in direct work with clients and in indirect work that supports their work with clients. The main types of direct work are advocacy, connecting to resources, experiential sharing, building community, relationship building, group facilitation, skill building/mentoring/goal setting, and socialization/self-esteem building. The main types of indirect work are group planning and development, administration, team communication, supervision/training, receiving support, education/awareness building, and information gathering and verification. In addition, peers also do work aimed at building relationships with staff and work aimed at legitimizing the peer role. Experience, approach, presence, role modeling, collaboration, challenge, and compromise can be seen as the tangible enactments of peers' philosophy of work.Conclusions: Candidates for positions as peer support workers require more than experience with mental health and/or addiction problems. The job description provided in this article may not be appropriate for all settings, but it will contribute to a better understanding of the peer support worker position, the skills required, and the types of expectations that could define successful fulfillment of the role. [ABSTRACT FROM AUTHOR]

Background: Shared decision making contributes to high quality healthcare by promoting a patient-centered approach. Patient involvement in selecting the components of a diabetes medication program that best match the patient's values and preferences may also enhance medication adherence and improve outcomes. Decision aids are tools designed to involve patients in shared decision making, but their adoption in practice has been limited. In this study, we propose to obtain a preliminary estimate of the impact of patient decision aids vs. usual care on measures of patient involvement in decision making, diabetes care processes, medication adherence, glycemic and cardiovascular risk factor control, and resource utilization. In addition, we propose to identify, describe, and explain factors that promote or inhibit the routine embedding of decision aids in practice. Methods/Design: We will be conducting a mixed-methods study comprised of a cluster-randomized, practical, multicentered trial enrolling clinicians and their patients (n = 240) with type 2 diabetes from rural and suburban primary care practices (n = 8), with an embedded qualitative study to examine factors that influence the incorporation of decision aids into routine practice. The intervention will consist of the use of a decision aid (Statin Choice and Aspirin Choice, or Diabetes Medication Choice) during the clinical encounter. The qualitative study will include analysis of video recordings of clinical encounters and in-depth, semi-structured interviews with participating patients, clinicians, and clinic support staff, in both trial arms. Discussion: Upon completion of this trial, we will have new knowledge about the effectiveness of diabetes decision aids in these practices. We will also better understand the factors that promote or inhibit the successful implementation and normalization of medication choice decision aids in the care of chronic patients in primary care practices. [ABSTRACT FROM AUTHOR]

Background: Disease management programs, especially those based on the Chronic Care Model (CCM), are increasingly common in the Netherlands. While disease management programs have been well-researched quantitatively and economically, less qualitative research has been done. The overall aim of the study is to explore how disease management programs are implemented within primary care settings in the Netherlands; this paper focuses on the early development and implementation stages of five disease management programs in the primary care setting, based on interviews with project leadership teams. Methods: Eleven semi-structured interviews were conducted at the five selected sites with sixteen professionals interviewed; all project directors and managers were interviewed. The interviews focused on each project's chosen chronic illness (diabetes, eating disorders, COPD, multi-morbidity, CVRM) and project plan, barriers to development and implementation, the project leaders' action and reactions, as well as their roles and responsibilities, and disease management strategies. Analysis was inductive and interpretive, based on the content of the interviews. After analysis, the results of this research on disease management programs and the Chronic Care Model are viewed from a traveling technology framework. Results: This analysis uncovered four themes that can be mapped to disease management and the Chronic Care Model: (1) changing the health care system, (2) patient-centered care, (3) technological systems and barriers, and (4) integrating projects into the larger system. Project leaders discussed the paths, both direct and indirect, for transforming the health care system to one that addresses chronic illness. Patient-centered care was highlighted as needed and a paradigm shift for many. Challenges with technological systems were pervasive. Project leaders managed the expenses of a traveling technology, including the social, financial, and administration involved. Conclusions: At the sites, project leaders served as travel guides, assisting and overseeing the programs as they traveled from the global plans to local actions. Project leaders, while hypothetically in control of the programs, in fact shared control of the traveling of the programs with patients, clinicians, and outside consultants. From this work, we can learn what roadblocks and expenses occur while a technology travels, from a project leader's point of view. [ABSTRACT FROM AUTHOR]

Background: South Africa's maternal mortality rate (625 deaths/100,000 live births) is high for a middle-income country, although over 90% of pregnant women utilize maternal health services. Alongside HIV/AIDS, barriers to Comprehensive Emergency Obstetric Care currently impede the country's Millenium Development Goals (MDGs) of reducing child mortality and improving maternal health. While health system barriers to obstetric care have been well documented, "patient-oriented" barriers have been neglected. This article explores affordability, availability and acceptability barriers to obstetric care in South Africa from the perspectives of women who had recently used, or attempted to use, these services. Methods: A mixed-method study design combined 1,231 quantitative exit interviews with sixteen qualitative in-depth interviews with women (over 18) in two urban and two rural health sub-districts in South Africa. Between June 2008 and September 2009, information was collected on use of, and access to, obstetric services, and socioeconomic and demographic details. Regression analysis was used to test associations between descriptors of the affordability, availability and acceptability of services, and demographic and socioeconomic predictor variables. Qualitative interviews were coded deductively and inductively using ATLAS ti.6. Quantitative and qualitative data were integrated into an analysis of access to obstetric services and related barriers. Results: Access to obstetric services was impeded by affordability, availability and acceptability barriers. These were unequally distributed, with differences between socioeconomic groups and geographic areas being most important. Rural women faced the greatest barriers, including longest travel times, highest costs associated with delivery, and lowest levels of service acceptability, relative to urban residents. Negative provider-patient interactions, including staff inattentiveness, turning away women in early-labour, shouting at patients, and insensitivity towards those who had experienced stillbirths, also inhibited access and compromised quality of care. Conclusions: To move towards achieving its MDGs, South Africa cannot just focus on increasing levels of obstetric coverage, but must systematically address the access constraints facing women during pregnancy and delivery. More needs to be done to respond to these "patient-oriented" barriers by improving how and where services are provided, particularly in rural areas and for poor women, as well as altering the attitudes and actions of health care providers. [ABSTRACT FROM AUTHOR]

Background: HIV/AIDS is fast becoming a chronic disease with the advent of antiretroviral drugs, therefore making home based care key in the management of chronically ill HIV/AIDS patient. The objective of this study was to determine the perception and practice of health care workers on HIV/AIDS related home based care in the health facilities in Ogun state, Nigeria. Methods: This study is an analytical cross-sectional study. A multistage cluster sampling technique was used to obtain a representative sample of the primary health care workers in Ogun state. An interviewer administered structured questionnaire was administered by trained health workers to elicit the required information. Result: A total of 350 health care workers were interviewed, 70% of the respondents could adequately describe the components of home based care. Only 38.7% were aware of the National guideline on home based care practices and 17.1% believe that home based care will not significantly improve the prognosis of PLWAs. Few 19.1% had ever been trained or ever involved 16.6% in home based care practices. Only 20 [5.7%] are involved on a weekly basis, 16 [4.6%] monthly and 22 [6.3%] quarterly. Reasons given for non implementation of home based care are inadequate number of healthcare workers 45%, lack of political will 24.4%, lack of implementation by facility managers 14% and inadequate funds 16.6%. Factors that were significantly associated with the practice of home based care were perception of its relevance in improving prognosis [OR = 54.21, C.I = 23.22-129.52] and presence of a support group in the facility [OR = 4.80, C.I = 2.40-9.57]. There was however no statistically significant relationship between adequate knowledge of home based care [OR = 0.78, C.I = 0.39-1.54] and previous training on home based care (OR = 1.43, C.I = 0.66-3.06]. Conclusion: The practice of home based care for HIV/AIDS among the study population is low and it is greatly influenced by perception of its effectiveness and relevance. The study recommends that the health care workers should be adequately educated on the importance of home based care in the management of chronic illnesses in order to enhance its practice. [ABSTRACT FROM AUTHOR]

Background: Economic evaluation of newborn screening poses specific methodological challenges. Amongst others, these challenges refer to the use of quality adjusted life years (QALYs) in newborns, and which costs and outcomes need to be considered in a full evaluation of newborn screening programmes. Because of the increasing scale and scope of such programmes, a better understanding of the methods of high-quality economic evaluations may be crucial for both producers/authors and consumers/reviewers of newborn screening-related economic evaluations. The aim of this study was therefore to develop specific guidelines designed to assess and improve the methodological quality of economic evaluations in newborn screening. Methods: To develop the guidelines, existing guidelines for assessing the quality of economic evaluations were identified through a literature search, and were reviewed and consolidated using a deductive iterative approach. In a subsequent test phase, these guidelines were applied to various economic evaluations which acted as case studies. Results: The guidelines for assessing and improving the methodological quality of economic evaluations in newborn screening are organized into 11 categories: "bibliographic details", "study question and design", "modelling", "health outcomes", "costs", "discounting", "presentation of results", "sensitivity analyses", "discussion", "conclusions", and "commentary". Conclusions: The application of the guidelines highlights important issues regarding newborn screening-related economic evaluations, and underscores the need for such issues to be afforded greater consideration in future economic evaluations. The variety in methodological quality detected by this study reveals the need for specific guidelines on the appropriate methods for conducting sound economic evaluations in newborn screening. [ABSTRACT FROM AUTHOR]

Background: The working population is ageing, which will increase the number of workers with chronic health complaints, and, as a consequence, the number of workers seeking health care. It is very important to understand factors that influence medical care-seeking in order to control the costs. I will investigate which work characteristics independently attribute to later care-seeking in order to find possibilities to prevent unnecessary or inefficient care-seeking. Methods: Data were collected in a longitudinal two-wave study (n = 2305 workers). The outcome measures were visits (yes/no and frequency) to a general practitioner (GP), a physical therapist, a medical specialist and/or a mental health professional. Multivariate regression analyses were carried out separately for men and women for workers with health complaints. Results: In the Dutch working population, personal, health, and work characteristics, but not sickness absence, were associated with later care-seeking. Work characteristics independently attributed to medical care-seeking but only for men and only for the frequency of visits to the GP. Women experience more health complaints and seek health care more often than men. For women, experiencing a work handicap (health complaints that impede work performance) was the only work characteristic associated with more care-seeking (GP). For men, work characteristics that led to less care-seeking were social support by colleagues (GP frequency), high levels of decision latitude (GP frequency) and high levels of social support by the supervisor (medical specialist). Other work characteristics led to more care-seeking: high levels of engagement (GP), full time work (GP frequency) and experiencing a work handicap (physical therapist). Conclusions: We can conclude that personal and health characteristics are most important when explaining medical care-seeking in the Dutch working population. Work characteristics independently attributed to medical care-seeking but only for men and only for the frequency of visits to the GP. The association between work characteristics and later medical care-seeking differed between health care providers and between men and women. If we aim at reducing health care costs for workers by preventing unnecessary or inefficient care, it is important to reduce the number of workers that report that health complaints impede their work performance. The supervisor could provide more social support, closely monitor workload in combination with work pressure and decision latitude, and when possible help to adjust working conditions. Health care providers could reduce medical costs by taking the work relatedness of health complaints into account and act accordingly, by decreasing the time to referral and waiting lists, and by providing appropriate care and avoiding unnecessary or harmful care. [ABSTRACT FROM AUTHOR]

Background: Assessment of patients' views are essential to provide a patient-centred health service and to evaluating quality of care. As no standardized and validated system for measuring patients' experiences in accident and emergency departments existed, we have developed the Consumer Quality index for the accident and emergency department (CQI A&E). Methods: Qualitative research has been undertaken to determine the content validity of the CQI A&E. In order to assess psychometric characteristics an 84-item questionnaire was sent to 653 patients who had attended a large A&E in the Netherlands. Also, fifty importance questions were added to determine relevance of the questions and for future calculations of improvement scores. Exploratory factor analysis was applied to detect the domains of the questionnaire. Results: Survey data of 304 (47%) patients were used for the analysis. The first exploratory factor analysis resulted in three domains based on 13 items: 'Attitude of the healthcare professionals', 'Environment and impression of the A&E' and 'Respect for and explanation to the patient'. The first two had an acceptable internal consistency. The second analysis, included 24 items grouped into 5 domains: 'Attitude of the healthcare professionals', 'Information and explanation', 'Environment of the A&E','Leaving the A&E' and 'General information and rapidity of care'. All factors were internal consistent. According to the patients, the three most important aspects in healthcare performance in the A&E were: trust in the competence of the healthcare professionals, hygiene in the A&E and patients' health care expectations. In general, the highest improvement scores concerned patient information. Conclusions: The Consumer Quality index for the accident and emergency department measures patients' experiences of A&E healthcare performance. Preliminary psychometric characteristics are sufficient to justify further research into reliability and validity. [ABSTRACT FROM AUTHOR]

Background: The adoption of new medicines is influenced by a complex set of social processes that have been widely examined in terms of individual prescribers' information-seeking and decision-making behaviour. However, quantitative, population-wide analyses of how long it takes for new healthcare practices to become part of mainstream practice are rare. Methods: We applied a Bass diffusion model to monthly prescription volumes of 103 often-prescribed drugs in Australia (monthly time series data totalling 803 million prescriptions between 1992 and 2010), to determine the distribution of adoption rates. Our aim was to test the utility of applying the Bass diffusion model to national-scale prescribing volumes. Results: The Bass diffusion model was fitted to the adoption of a broad cross-section of drugs using national monthly prescription volumes from Australia (median R2 = 0.97, interquartile range 0.95 to 0.99). The median time to adoption was 8.2 years (IQR 4.9 to 12.1). The model distinguished two classes of prescribing patterns - those where adoption appeared to be driven mostly by external forces (19 drugs) and those driven mostly by social contagion (84 drugs). Those driven more prominently by internal forces were found to have shorter adoption times (p = 0.02 in a non-parametric analysis of variance by ranks). Conclusion: The Bass diffusion model may be used to retrospectively represent the patterns of adoption exhibited in prescription volumes in Australia, and distinguishes between adoption driven primarily by external forces such as regulation, or internal forces such as social contagion. The eight-year delay between the introduction of a new medicine and the adoption of the prescribing practice suggests the presence of system inertia in Australian prescribing practices. [ABSTRACT FROM AUTHOR]

Background: Mental health problems are disproportionately higher amongst homeless people. Many barriers exist for homeless people with mental health problems in accessing treatment yet little research has been done on service provision and quality of care for this group. The aim of this paper is to assess current service provision and identify barriers to care for homeless people with mental health problems in 14 European capital cities. Method: Two methods of data collection were employed; (i) In two highly deprived areas in each of the 14 European capital cities, homeless-specific services providing mental health, social care or general health services were assessed. Data were obtained on service characteristics, staff and programmes provided. (ii) Semi-structured interviews were conducted in each area with experts in mental health care provision for homeless people in order to determine the barriers to care and ways to overcome them. Results: Across the 14 capital cities, 111 homeless-specific services were assessed. Input from professionally qualified mental health staff was reported as low, as were levels of active outreach and case finding. Out-of-hours service provision appears inadequate and high levels of service exclusion criteria were evident. Prejudice in the services towards homeless people, a lack of co-ordination amongst services, and the difficulties homeless people face in obtaining health insurance were identified as major barriers to service provision. Conclusions: While there is variability in service provision across European capital cities, the reported barriers to service accessibility are common. Homeless-specific services are more responsive to the initial needs of homeless people with mental health problems, while generic services tend to be more conducive to long term care. Further research is needed to determine the effectiveness of different service delivery models, including the most effective coordination of homeless specific and generic services. [ABSTRACT FROM AUTHOR]

Background: Health facilities require teams of health workers with complementary skills and responsibilities to efficiently provide quality care. In low-income countries, failure to attract and retain health workers in rural areas reduces population access to health services and undermines facility performance, resulting in poor health outcomes. It is important that governments consider health worker preferences in crafting policies to address attraction and retention in underserved areas. Methods: We investigated preferences for job characteristics among final year medical, nursing, pharmacy, and laboratory students at select universities in Uganda. Participants were administered a cadre-specific discrete choice experiment that elicited preferences for attributes of potential job postings they were likely to pursue after graduation. Job attributes included salary, facility quality, housing, length of commitment, manager support, training tuition, and dual practice opportunities. Mixed logit models were used to estimate stated preferences for these attributes. Results: Data were collected from 246 medical students, 132 nursing students, 50 pharmacy students and 57 laboratory students. For all student-groups, choice of job posting was strongly influenced by salary, facility quality and manager support, relative to other attributes. For medical and laboratory students, tuition support for future training was also important, while pharmacy students valued opportunities for dual practice. Conclusions: In Uganda, financial and non-financial incentives may be effective in attracting health workers to underserved areas. Our findings contribute to mounting evidence that salary is not the only important factor health workers consider when deciding where to work. Better quality facilities and supportive managers were important to all students. Similarities in preferences for these factors suggest that team-based, facility-level strategies for attracting health workers may be appropriate. Improving facility quality and training managers to be more supportive of facility staff may be particularly cost-effective, as investments are borne once while benefits accrue to a range of health workers at the facility. [ABSTRACT FROM AUTHOR]