Health system interventions for adults with type 2 diabetes in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Effective health system interventions may help address the disproportionate burden of diabetes in low- and middle-income countries (LMICs). We assessed the impact of health system interventions to improve outcomes for adults with type 2 diabetes in LMICs.

METHODS AND FINDINGS

We searched Ovid MEDLINE, Cochrane Library, EMBASE, African Index Medicus, LILACS, and Global Index Medicus from inception of each database through February 24, 2020. We included randomized controlled trials (RCTs) of health system interventions targeting adults with type 2 diabetes in LMICs. Eligible studies reported at least 1 of the following outcomes: glycemic change, mortality, quality of life, or cost-effectiveness. We conducted a meta-analysis for the glycemic outcome of hemoglobin A1c (HbA1c). GRADE and Cochrane Effective Practice and Organisation of Care methods were used to assess risk of bias for the glycemic outcome and to prepare a summary of findings table. Of the 12,921 references identified in searches, we included 39 studies in the narrative review of which 19 were cluster RCTs and 20 were individual RCTs. The greatest number of studies were conducted in the East Asia and Pacific region (n = 20) followed by South Asia (n = 7). There were 21,080 total participants enrolled across included studies and 10,060 total participants in the meta-analysis of HbA1c when accounting for the design effect of cluster RCTs. Non-glycemic outcomes of mortality, health-related quality of life, and cost-effectiveness had sparse data availability that precluded quantitative pooling. In the meta-analysis of HbA1c from 35 of the included studies, the mean difference was -0.46% (95% CI -0.60% to -0.31%, I2 87.8%, p < 0.001) overall, -0.37% (95% CI -0.64% to -0.10%, I2 60.0%, n = 7, p = 0.020) in multicomponent clinic-based interventions, -0.87% (-1.20% to -0.53%, I2 91.0%, n = 13, p < 0.001) in pharmacist task-sharing studies, and -0.27% (-0.50% to -0.04%, I2 64.1%, n = 7, p = 0.010) in trials of diabetes education or support alone. Other types of interventions had few included studies. Eight studies were at low risk of bias for the summary assessment of glycemic control, 15 studies were at unclear risk, and 16 studies were at high risk. The certainty of evidence for glycemic control by subgroup was moderate for multicomponent clinic-based interventions but was low or very low for other intervention types. Limitations include the lack of consensus definitions for health system interventions, differences in the quality of underlying studies, and sparse data availability for non-glycemic outcomes.

CONCLUSIONS

In this meta-analysis, we found that health system interventions for type 2 diabetes may be effective in improving glycemic control in LMICs, but few studies are available from rural areas or low- or lower-middle-income countries. Multicomponent clinic-based interventions had the strongest evidence for glycemic benefit among intervention types. Further research is needed to assess non-glycemic outcomes and to study implementation in rural and low-income settings.

Local patterns of social capital and sustenance of the Community-Based Health Planning Services (CHPS) policy: a qualitative comparative study in Ghana

OBJECTIVE

Social capital-the resources embedded in social relationships-has been associated with health severally. Notwithstanding, only a handful of studies have empirically examined how it shapes health policies. This paper extends the discourse by comparatively examining how variations in local patterns of structural and cognitive social capital underpin the successes and challenges in managing and sustaining the Community-Based Health Planning Services (CHPS) policy in Ghana. The CHPS is an intervention to address health inequalities.

DESIGN

Qualitative study involving individual in-depth interviews and focus group discussions using a semi-structured interview guide. Thematic analysis approach, inspired by McConnell's typology of policy success (or failure) was adopted.

SETTING

Two rural communities in two districts in Ashanti region in Ghana.

PARTICIPANTS

Thirty-two primary participants as well as four health personnel and four traditional and political leaders.

RESULTS

Both structural and cognitive components of social capital underpinned efficient functioning of the CHPS initiative regarding funding, patronage and effective information transmission. Sufficient level of social capital in a community enhanced understanding of the nature and purpose of the CHPS policy as well as complementary ones such as the referral policy. Contrary to popular conclusions, it was discovered that the influence of social capital was not necessarily embedded in its quantity but the extent of conscious activation and application. Furthermore, the findings contravened the assertion that social capital may be less potent in small-sized communities. However, elevated levels of cognitive social capital encouraged people to access the CHPS on credit or even for free, which was injurious to its sustenance.

CONCLUSION

The CHPS initiative, and pro-poor policies alike, are more likely to thrive in localities with sufficient structural and cognitive social capital. Lack of it may render the CHPS susceptible to recurrent, yet preventable challenges.

Willing but unable? Extending theory to investigate community capacity to participate in Ghana's community-based health planning and service implementation

While primary health care programmes based on community participation are widely implemented in low- and middle- income settings, empirical evidence on whether and to what extent local people have the capacity to participate, support and drive such programmes scale up is scant in these countries. This paper assessed the level of community capacity to participate in one such programme - the Community-Based Health Planning and Service (CHPS) in Ghana. The capacity assessments were drawn from Chaskin's (2001) theorised indicators of community capacity with modifications to include: sense of community; community members commitment; community leadership commitment; problem solving mechanisms; and access to resources. These capacity measures guided the design of an interview guide used to collect data from community informants, frontline health providers (FLP) and district health managers. Key qualitative themes were built into a questionnaire administered to households selected through systematic sampling approach. Findings showed that growing individualism, low trust in neighbours and apathetic behaviours undermined the capacity of mutual support for CHPS. The capacity to support CHPS was high for local leadership and community social mobilisation groups who often dedicated time to working with FLP to promote maternal and reproductive health service use, and in advocating broader support for CHPS. Within the wider community, commitment to voluntarism was low as members perceived CHPS to be owned by, and run on government funds and resources. Poor voluntarism was compounded by poverty that crippled the capacity to provide needed resource support for CHPS. Findings have great implications for building strong capable communities for participation in community oriented health programmes.

What conditions enable decentralization to improve the health system? Qualitative analysis of perspectives on decision space after 25 years of devolution in the Philippines

BACKGROUND

Decentralization is promoted as a strategy to improve health system performance by bringing decision-making closer to service delivery. Some studies have investigated if decentralization actually improves the health system. However, few have explored the conditions that enable it to be effective. To determine these conditions, we have analyzed the perspectives of decision-makers in the Philippines where devolution, one form of decentralization, was introduced 25 years ago.

METHODS

Drawing from the "decision space" approach, we interviewed 27 decision-makers with an average of 23.6 years of working across different levels of the Philippine government health sector and representing various local settings. Qualitative analysis followed the "Framework Method." Conditions that either enable or hinder the effectiveness of decentralization were identified by exploring decision-making in five health sector functions.

RESULTS

These conditions include: for planning, having a multi-stakeholder approach and monitoring implementation; for financing and budget allocation, capacities to raise revenues at local levels and pooling of funds at central level; for resource management, having a central level capable of augmenting resource needs at local levels and a good working relationship between the local health officer and the elected local official; for program implementation and service delivery, promoting innovation at local levels while maintaining fidelity to national objectives; and for monitoring and data management, a central level capable of ensuring that data collection from local levels is performed in a timely and accurate manner.

CONCLUSIONS

The Philippine experience suggests that decentralization is a long and complex journey and not an automatic solution for enhancing service delivery. The role of the central decision-maker (e.g. Ministry of Health) remains important to assist local levels unable to perform their functions well. It is policy-relevant to analyze the conditions that make decentralization work and the optimal combination of decentralized and centralized functions that enhance the health system.

State-Level Community Benefit Regulation and Nonprofit Hospitals' Provision of Community Benefits

Do nonprofit hospitals provide enough community benefits to justify their tax exemptions? States have sought to enhance nonprofit hospitals' accountability and oversight through regulation, including requirements to report community benefits, conduct community health needs assessments, provide minimum levels of community benefits, and adhere to minimum income eligibility standards for charity care. However, little research has assessed these regulations' impact on community benefits. Using 2009-11 Internal Revenue Service data on community benefit spending for more than eighteen hundred hospitals and the Hilltop Institute's data on community benefit regulation, we investigated the relationship between these four types of regulation and the level and types of hospital-provided community benefits. Our multivariate regression analyses showed that only community health needs assessments were consistently associated with greater community benefit spending. The results for reporting and minimum spending requirements were mixed, while minimum income eligibility standards for charity care were unrelated to community benefit spending. State adoption of multiple types of regulation was consistently associated with higher levels of hospital-provided community benefits, possibly because regulatory intensity conveys a strong signal to the hospital community that more spending is expected. This study can inform efforts to design regulations that will encourage hospitals to provide community benefits consistent with policy makers' goals.

Developing a sustainable child and family service system after a community tragedy: Lessons from Sandy Hook

This paper describes a systematic approach to assessing community services post-Sandy Hook shooting. An evaluation team was invited to develop a sustainability plan for community services in Newtown. Service organizations, providers and families were interviewed. Descriptive statistics were used to characterize the range of services; respondent perspectives were coded using content analysis. We found that Newtown has a broad array of community services, but respondent groups varied in their perceptions of service adequacy. Consensus existed about core components of an ideal service system, including centralizing access; coordinating care; personalizing and tailoring services for families; and providing evidence-based care. The strategic community assessment approach developed here may inform how communities examine their service capacity and develop sustainability plans post-disaster.

Contextual variations in costs for a community health strategy implemented in rural, peri-urban and nomadic sites in Kenya

BACKGROUND

Many low and middle income countries have developed community health strategies involving lay health workers, to complement and strengthen public health services. This study explores variations in costing parameters pertinent to deployment of community health volunteers across different contexts outlining considerations for costing program scale-up.

METHODS

The study used quasi experimental study design and employed both quantitative and qualitative methods to explore community health unit implementation activities and costs and compare costs across purposively selected sites that differed socially, economically and ecologically. Data were collected from November 2010 to December 2013 through key informant interviews and focus group discussions. We interviewed 16 key informants (eight District community health strategy focal persons, eight frontline field officers), and eight focus group discussions (four with community health volunteers and four with community health committee) and 560 sets of monthly cost data. Cost data were tabulated using Microsoft Excel. Qualitative data were transcribed and coded using a content analysis framework.

RESULTS

Four critical elements: attrition rates for community health volunteers, geography and population density, livelihood opportunity costs and benefits, and social opportunity benefits, drove cost variations across the three sites. Attrition rate was highest in peri-urban site where population is highly mobile and lowest in nomadic site. More households were covered by community health workers in the peri-urban area making per capita costs considerably less than in the nomadic settings where long distances had to be covered to reach sparsely distributed households. Livelihood opportunity costs for Community Health Volunteers were highest in nomadic setting, while peri-urban ones reported substantial employability benefits resulting from training. Social opportunity benefits were highest in rural site.

CONCLUSIONS

Results show that costs of implementing community health strategy varied due to different area contextual factors in Kenya. This study identified four critical elements that drive cost variations: attrition rates for community health volunteers, geography and population density, livelihood opportunity costs and benefits, and social opportunity benefits. Health programme managers and policy-makers need to pay attention to details of contextual factors in costing for effective implementation of community health strategies.

Realistic Expectations: Investing in Organizational Capacity Building for Chronic Disease Prevention

Purpose.

This article presents findings that explore investment in organizational capacity building for chronic disease prevention. Specifically, this analysis examines variation in investment inputs, intervention outputs, and capacity changes to inform expectations of health-promotion capacity-building investment.

Design/Setting.

This multiple case study involving both qualitative and quantitative data is based on seven provincial dissemination projects involved in the Canadian Heart Health Initiative.

Methods.

Data on investment, number, and type of capacity-building activities and capacity changes come from a questionnaire, key informant interviews, and project report analysis. Quantitative data were analyzed descriptively and for trends, while qualitative data were analyzed thematically.

Results.

Per capita investments in capacity building ranged from a low of $0.21 in Ontario to $167.41 in Prince Edward Island. Multiple, tailored capacity-building interventions were used in each project. Mostly positive but modest changes were observed in at least five dimensions of capacity in all but one project.

Conclusion.

These findings reveal that capacity building for chronic disease prevention requires a long-term investment and is context specific. Even limited investment can produce interventions that appear to positively influence capacity for chronic disease prevention. The findings also suggest an urgent need to expand surveillance to include indicators of capacity-building investments and interventions to allow policy makers to make more informed decisions about investments in public health.

Reducing cancer disparities through community engagement in policy development: the role of cancer councils

Cancer is the second leading cause of death in the U.S and a source of large racial and ethnic disparities in population health. Policy development is a powerful but sometimes overlooked public health tool for reducing cancer burden and disparities. Along with other partners in the public health system, community-based organizations such as local cancer councils can play valuable roles in developing policies that are responsive to community needs and in mobilizing resources to support policy adoption and implementation. This paper examines the current and potential roles played by local cancer councils to reduce cancer burden and disparities. Responsive public health systems require vehicles for communities to engage in policy development. Cancer councils provide promising models of engagement. Untapped opportunities exist for enhancing policy development through cancer councils, such as expanding targets of engagement to include private-sector stakeholders and expanding methods of engagement utilizing the Affordable Care Act's Prevention and Public Health Fund.

Measuring health system strengthening: application of the balanced scorecard approach to rank the baseline performance of three rural districts in Zambia

Introduction

There is growing interest in health system performance and recently WHO launched a report on health systems strengthening emphasising the need for close monitoring using system-wide approaches. One recent method is the balanced scorecard system. There is limited application of this method in middle- and low-income countries. This paper applies the concept of balanced scorecard to describe the baseline status of three intervention districts in Zambia.

Methodology

The Better Health Outcome through Mentoring and Assessment (BHOMA) project is a randomised step-wedged community intervention that aims to strengthen the health system in three districts in the Republic of Zambia. To assess the baseline status of the participating districts we used a modified balanced scorecard approach following the domains highlighted in the MOH 2011 Strategic Plan.

Results

Differences in performance were noted by district and residence. Finance and service delivery domains performed poorly in all study districts. The proportion of the health workers receiving training in the past 12 months was lowest in Kafue (58%) and highest in Luangwa district (77%). Under service capacity, basic equipment and laboratory capacity scores showed major variation, with Kafue and Luangwa having lower scores when compared to Chongwe. The finance domain showed that Kafue and Chongwe had lower scores (44% and 47% respectively). Regression model showed that children's clinical observation scores were negatively correlated with drug availability (coeff −0.40, p = 0.02). Adult clinical observation scores were positively association with adult service satisfaction score (coeff 0.82, p = 0.04) and service readiness (coeff 0.54, p = 0.03).

Conclusion

The study applied the balanced scorecard to describe the baseline status of 42 health facilities in three districts of Zambia. Differences in performance were noted by district and residence in most domains with finance and service delivery performing poorly in all study districts. This tool could be valuable in monitoring and evaluation of health systems.

Harnessing the power of the grassroots to conduct public health research in sub-Saharan Africa: a case study from western Kenya in the adaptation of community-based participatory research (CBPR) approaches

BACKGROUND

Community-based participatory research (CBPR) is a collaborative approach to research that involves the equitable participation of those affected by an issue. As the field of global public health grows, the potential of CBPR to build capacity and to engage communities in identification of problems and development and implementation of solutions in sub-Saharan Africa has yet to be fully tapped. The Orphaned and Separated Children's Assessments Related to their Health and Well-Being (OSCAR) project is a longitudinal cohort of orphaned and non-orphaned children in Kenya. This paper will describe how CBPR approaches and principles can be incorporated and adapted into the study design and methods of a longitudinal epidemiological study in sub-Saharan Africa using this project as an example.

METHODS

The CBPR framework we used involves problem identification, feasibility and planning; implementation; and evaluation and dissemination. This case study will describe how we have engaged the community and adapted CBPR methods to OSCAR's Health and Well-being Project's corresponding to this framework in four phases: 1) community engagement, 2) sampling and recruitment, 3) retention, validation, and follow-up, and 4) analysis, interpretation and dissemination.

RESULTS

To date the study has enrolled 3130 orphaned and separated children, including children living in institutional environments, those living in extended family or other households in the community, and street-involved children and youth. Community engagement and participation was integral in refining the study design and identifying research questions that were impacting the community. Through the participation of village Chiefs and elders we were able to successfully identify eligible households and randomize the selection of participants. The on-going contribution of the community in the research process has been vital to participant retention and data validation while ensuring cultural and community relevance and equity in the research agenda.

CONCLUSION

CBPR methods have the ability to enable and strengthen epidemiological and public health research in sub-Saharan Africa within the social, political, economic and cultural contexts of the diverse communities on the continent. This project demonstrates that adaptation of these methods is crucial to the successful implementation of a community-based project involving a highly vulnerable population.

Paths of convergence for agriculture, health, and wealth

This special feature calls for forward thinking around paths of convergence for agriculture, health, and wealth. Such convergence aims for a richer integration of smallholder farmers into national and global agricultural and food systems, health systems, value chains, and markets. The articles identify analytical innovation, where disciplines intersect, and cross-sectoral action where single, linear, and siloed approaches have traditionally dominated. The issues addressed are framed by three main themes: (i) lessons related to agricultural and food market growth since the 1960s; (ii) experiences related to the integration of smallholder agriculture into national and global business agendas; and (iii) insights into convergence-building institutional design and policy, including a review of complexity science methods that can inform such processes. In this introductory article, we first discuss the perspectives generated for more impactful policy and action when these three themes converge. We then push thematic boundaries to elaborate a roadmap for a broader, solution-oriented, and transdisciplinary approach to science, policies, and actions. As the global urban population crosses the 50% mark, both smallholder and nonsmallholder agriculture are keys in forging rural-urban links, where both farm and nonfarm activities contribute to sustainable nutrition security. The roadmaps would harness the power of business to reduce hunger and poverty for millions of families, contribute to a better alignment between human biology and modern lifestyles, and stem the spread of noncommunicable chronic diseases.

A research agenda for malaria eradication: health systems and operational research

Health systems research and development is needed to support the global malaria eradication agenda. In this paper, we (the malERA Consultative Group on Health Systems and Operational Research) focus on the health systems needs of the elimination phase of malaria eradication and consider groupings of countries at different stages along the pathway to elimination. We examine the difference between the last attempt at eradication of malaria and more recent initiatives, and consider the changing health system challenges as countries make progress towards elimination. We review recent technological and theoretical developments related to health systems and the renewed commitment to strengthening health systems for universal access and greater equity. Finally, we identify a number of needs for research and development, including tools for analyzing and improving effective coverage and strengthening decision making and discuss the relevance of these needs at all levels of the health system from the community to the international level.

Financial preconditions for successful community initiatives for the uninsured

Community-based initiatives are increasingly being implemented as a strategy to address the health needs of the community, with a growing body of evidence on successes of various initiatives. This study addresses financial status indicators (preconditions) that might predict where community-based initiatives might have a better chance for success. We evaluated five community-based initiatives funded by the Communities in Charge (CIC) program sponsored by the Robert Wood Johnson Foundation. These initiatives focus on increasing access by easing financial barriers to care for the uninsured. At each site, we collected information on financial status indicators and interviewed key personnel from health services delivery and financing organizations. With full acknowledgment of the caveats associated with generalizations based on a small number of observations, we suggest four financial preconditions associated with successful initiation of CIC programs: (1) uncompensated care levels that negatively affect profitability, (2) reasonable financial stability of providers, (3) stable health insurance market, and (4) the potential to create new sources of funding. In general, sites that demonstrate successful program initiation are financially stressed enough by uncompensated care to gain the attention of local healthcare providers. However, they are not so strained and so concerned about revenue sources that they cannot afford to participate in the initiative. In addition to political and managerial indicators, we suggest that planning for community-based initiatives should include financial indicators of current health services delivery and financing organizations and consideration of whether they meet preconditions for success.

Factors influencing implementation of the Community Health Fund in Tanzania

Although prepayment schemes are being hailed internationally as part of a solution to health care financing problems in low-income countries, literature has raised problems with such schemes. This paper reports the findings of a study that examined the factors influencing low enrollment in Tanzania's health prepayment schemes (Community Health Fund). The paper argues that district managers had a direct influence over the factors explaining low enrollment and identified in other studies (inability to pay membership contributions, low quality of care, lack of trust in scheme managers and failure to see the rationale to insure). District managers' actions appeared, in turn, to be at least partly a response to the manner of this policy's implementation. In order better to achieve the objectives of prepayment schemes, it is important to focus attention on policy implementers, who are capable of re-shaping policy during its implementation, with consequences for policy outcomes.

Creative partnerships for community health improvement: a qualitative evaluation of the Healthy Carolinians community micro-grant project

This qualitative study evaluated a recent innovative strategy used to involve community-based organizations (CBOs) in implementing health-related projects through locally administered microgrants. The purpose of this study was to identify key elements that enabled the success of the CBO projects, barriers and challenges to project success, and ways to effectively engage CBOs as partners in local health initiatives. In addition, this study sought to identify aspects of this approach that can be replicated. Study findings revealed that microfinancing CBOs aided in building partnerships, developing local leadership and expertise, and providing resources that enabled progress toward CBO missions and goals. These positive outcomes far out-weighed barriers and challenges faced by CBOs. Furthermore, the results of this study revealed ideas and information that provide useful guidelines for establishing and administering microgrant projects through local organizations that encourage community groups to design and implement community based health initiatives.

Characteristics of physical activity levels among trail users in a U.S. national sample

BACKGROUND

The Task Force on Community Preventive Services strongly recommends environmental interventions that include enhanced access to opportunities for physical activity, such as walking and cycling trails. Although accumulating evidence indicates that trails can be effective in increasing physical activity, little is known about trail users.

METHODS

Cross-sectional analysis of a national sample of 3717 adults from the HealthStyles and ConsumerStyles surveys using logistic regression to determine physical activity patterns and sociodemographic correlates related to trail use, and to identify support regarding trail development policies.

RESULTS

Almost 13% (12.7%) of the sample reported using trails at least once a month and 24.3% at least once a week. People who reported using trails at least once a week were twice as likely than people who reported rarely or never using trails to meet physical activity recommendations (odds ratio=2.3, 95% confidence interval=1.9-2.8). Nearly half (43.6%) of the non-trail users supported expanded public spaces for people to exercise, and 36.4% of the non-trail users reported that they would be willing to pay more taxes to build more parks and trails in their community.

CONCLUSIONS

Community trails facilitate physical activity, and almost half of frequent trail users report that access to trails and other green space is important in choosing a place to live. These results support the need for prospective research on whether newly built trails promote physical activity in previously inactive people.

Tackling social determinants of health through community based initiatives

Women are often the key to improving a population's health, and this is especially true in the Eastern Mediterranean region. Projects that empower women and provide basic needs are transforming poor communities

Preparing for the unknown, responding to the known: communities and public health preparedness

More than four years after September 11, 2001, bioterrorism preparedness remains a high priority for federal, state, and local governments. With reasonably flexible federal funding, communities have strengthened their ability to respond to public health emergencies, according to assessments by stakeholders and market observers. Collaborative relationships developed for bioterrorism preparedness have proved useful in addressing other threats, such as natural disasters and infectious disease outbreaks. Major ongoing challenges include funding constraints, inadequate surge capacity, public health workforce shortages, competing priorities, and jurisdictional issues.

Ecologists can enable communities to implement malaria vector control in Africa

BACKGROUND

Integrated vector management (IVM) for malaria control requires ecological skills that are very scarce and rarely applied in Africa today. Partnerships between communities and academic ecologists can address this capacity deficit, modernize the evidence base for such approaches and enable future scale up.

METHODS

Community-based IVM programmes were initiated in two contrasting settings. On Rusinga Island, Western Kenya, community outreach to a marginalized rural community was achieved by University of Nairobi through a community-based organization. In Dar es Salaam, Tanzania, Ilala Municipality established an IVM programme at grassroots level, which was subsequently upgraded and expanded into a pilot scale Urban Malaria Control Programme with support from national academic institutes.

RESULTS

Both programmes now access relevant expertise, funding and policy makers while the academic partners benefit from direct experience of community-based implementation and operational research opportunities. The communities now access up-to-date malaria-related knowledge and skills for translation into local action. Similarly, the academic partners have acquired better understanding of community needs and how to address them.

CONCLUSION

Until sufficient evidence is provided, community-based IVM remains an operational research activity. Researchers can never directly support every community in Africa so community-based IVM strategies and tactics will need to be incorporated into undergraduate teaching programmes to generate sufficient numbers of practitioners for national scale programmes. Academic ecologists at African institutions are uniquely positioned to enable the application of practical environmental and entomological skills for malaria control by communities at grassroots level and should be supported to fulfil this neglected role.

Ecologists can enable communities to implement malaria vector control in Africa

BACKGROUND

Integrated vector management (IVM) for malaria control requires ecological skills that are very scarce and rarely applied in Africa today. Partnerships between communities and academic ecologists can address this capacity deficit, modernize the evidence base for such approaches and enable future scale up.

METHODS

Community-based IVM programmes were initiated in two contrasting settings. On Rusinga Island, Western Kenya, community outreach to a marginalized rural community was achieved by University of Nairobi through a community-based organization. In Dar es Salaam, Tanzania, Ilala Municipality established an IVM programme at grassroots level, which was subsequently upgraded and expanded into a pilot scale Urban Malaria Control Programme with support from national academic institutes.

RESULTS

Both programmes now access relevant expertise, funding and policy makers while the academic partners benefit from direct experience of community-based implementation and operational research opportunities. The communities now access up-to-date malaria-related knowledge and skills for translation into local action. Similarly, the academic partners have acquired better understanding of community needs and how to address them.

CONCLUSION

Until sufficient evidence is provided, community-based IVM remains an operational research activity. Researchers can never directly support every community in Africa so community-based IVM strategies and tactics will need to be incorporated into undergraduate teaching programmes to generate sufficient numbers of practitioners for national scale programmes. Academic ecologists at African institutions are uniquely positioned to enable the application of practical environmental and entomological skills for malaria control by communities at grassroots level and should be supported to fulfil this neglected role.

Creating demand for sanitation and hygiene through Community Health Clubs: a cost-effective intervention in two districts in Zimbabwe

Unless strategies are found to galvanise rural communities and create a demand for sanitation, we cannot achieve the United Nations Millennium Development Goal of halving the 2.4 billion people without sanitation by the year 2015. This study describes an innovative methodology used in Zimbabwe--Community Health Clubs--which significantly changed hygiene behaviour and built rural demand for sanitation. In 1 year in Makoni District, 1244 health promotion sessions were held by 14 trainers, costing an average of US dollars 0.21 per beneficiary and involving 11,450 club members (68,700 beneficiaries). In Tsholotsho District, 2105 members participated in 182 sessions held by three trainers which cost US dollars 0.55 for each of the 12,630 beneficiaries. Within 2 years, 2400 latrines had been built in Makoni, and in Tsholotsho latrine coverage rose to 43% contrasted to 2% in the control area, with 1200 latrines being built in 18 months. Although Zimbabwe has historically relied on subsidies to stimulate sanitation, this intervention shows how total sanitation could be achievable. The remaining 57% of club members without latrines in Tsholotsho all practised faecal burial, a method previously unknown to them. Club members' hygiene was significantly different (p<0.0001) from a control group across 17 key hygiene practices including hand washing, showing that if a strong community structure is developed and the norms of a community are altered, sanitation and hygiene behaviour are likely to improve. This methodology could be scaled up to contribute to ambitious global targets.

Criteria for use in the evaluation of health impact assessments

This paper reports the conclusions of a recent workshop that was established to discuss how health impact assessments (HIAs) might be evaluated. The main purposes of HIA are: (a) to predict the consequences of different decisions; (b) to make the decision-making process more open by involving stakeholders; and (c) to inform the decision makers. 'Prediction', 'participation' and 'informing decision makers' are thus the three domains in which HIA should be evaluated. In the 'prediction' domain, process criteria scrutinize the methods used to see if it is likely that they would produce reliable predictions. Outcome criteria involve verifying the predictions, but this is frequently impractical and predictions for the counter factual (the option not chosen) can never be verified. In the 'participation' domain, process criteria examine the ways in which stakeholders were involved, while outcome criteria explore the degree to which the stakeholders felt included. In the 'informing decision makers' domain, process criteria are concerned with the communication between decision makers and those doing the HIA, and should reflect upon the relevance of the HIA content to the decision makers' agenda. Outcome criteria explore the degree to which the decision makers considered that they had been informed by the HIA. This paper concludes with suggestions for the types of information that should be included in HIA reports in order to permit the readers to make an assessment of the 'quality' of the HIA using the three domain criteria outlined above.

Selecting, implementing, and evaluating teen pregnancy prevention interventions: lessons from the CDC's Community Coalition Partnership Programs for the Prevention of Teen Pregnancy

PURPOSE

To summarize 13 communities' experiences with selecting, implementing, and evaluating teen pregnancy prevention interventions within the CDC Community Coalition Partnership Programs for the Prevention of Teen Pregnancy. The study focuses on decision-making processes and barriers encountered in five categories of interventions: reproductive health services, reproductive health education, parent-child communication, male involvement, and programs for pregnant and parenting teens.

METHODS

Telephone interviews were conducted with program directors, lead evaluators, and community coalition chairpersons in each of the 13 communities. The descriptive analysis explored factors that influenced community decisions to develop or not to develop interventions. These factors were analyzed by type of intervention.

RESULTS

Each community implemented an average of six interventions and operated them with a variety of funding sources. Interventions were selected on the basis of need, and the community needs and assets assessment process was "very important" for most reported interventions. Decision-making was influenced most often by project staff, the coalition, or related work groups. Teens were infrequently viewed as primary decision-makers in the selection of interventions. Communities with family planning services as hub agencies were more likely to address reproductive services and reproductive health education. Communities with child advocacy or youth-serving agencies were more likely to focus on other intervention categories. About two-thirds of the interventions were evaluated by either process or outcome measures, or by both.

CONCLUSIONS

This study highlights important lessons learned that should be considered in examinations of the overall effectiveness of this community coalition approach to the prevention of teen pregnancy.

Economic considerations of health literacy

Illiteracy is a critical economic and health care problem in the United States. People with low health literacy are more likely to report poor health, have an incomplete understanding of their health problems and treatment, and are at greater risk of hospitalization. Strategies and incentives for population health improvement affected by health literacy are recommended. Potential economic factors are discussed. Major nursing roles in the area of health literacy are reviewed.

Formative assessment of use of behavioral data in HIV prevention: Texas

A formative assessment was conducted with Texas HIV prevention community planning group (CPG) members, prevention provider staff, and supervisors of those staff to better understand how to enhance their use of epidemiologic and behavioral data in the selection and prioritization of prevention interventions. Semi-structured interviews, mail surveys, and content analysis of funding proposals were used to determine the current use of these data, their perceived value, and the most trusted sources for data. CPG members, prevention provider staff, and supervisors valued information from their peers and networking most, and made more use of socially available information than they did research or systematically collected assessment data. CPG members wanted more local data and data on specific sub-populations of interest. Prevention providers viewed the utility of behavioral data as limited, and were primarily concerned with the pragmatic aspects of fielding interventions; however, this group also expressed an interest in rapid community assessment methods and learning more about new and effective prevention interventions. These results led to the development of training and technical assistance materials.

Improving the use of data for HIV prevention decision making: lessons learned

HIV prevention community planning was developed to promote identification of local prevention priorities through a process that was evidence-based and provided community input. There are a variety of barriers to effective use of data in community planning which include characteristics of data (availability, timeliness, relevance to planning tasks), characteristics of planning group members and providers of data (e.g., skills in understanding and applying data), and social-organizational aspects of community-planning groups (CPGs). Lessons learned from this project illustrate how to create locally relevant sources of data, build data use skills of CPG members and data providers, and address social-organizational aspects of planning, while also better integrating community planning with implementation of prevention plans. Adaptation of tools and methods is discussed along with future considerations for research and planning practice.

Designing and Building New Local Public Health Agencies in Nebraska

Prior to 2001, the local public health system in Nebraska was weak, fragmented, and severely under funded. Local public health departments covered only 22 of the state's 93 counties. The Turning Point project provided the impetus for change by allowing a diverse group of public health stakeholders to develop a strategic plan for strengthening and transforming the public health system. The plan acted as a catalyst to use some of the Nebraska Tobacco Settlement Funds to provide dedicated state funding to build the local public health system. By June 2002, 16 new local public health departments had been organized, ultimately covering all of the 93 counties in the state. Some of the keys to long-term sustainability are creating a network of community health partners that support collaborative decision making, continually seeking input from the community, developing and implementing an education and training plan for public health professionals and local board of health members, and demonstrating accountability by documenting results and communicating them to policy makers and the general public.

A naturalistic inquiry on the impact of interventions aiming to improve health and the quality of life in the community

The goal of this study is to identify and describe variables contributing to the efficiency of health promotion interventions, and to assess whether these variables can serve as reliable and early indicators of the success of such interventions. The study sample includes 44 interventions selected through a network of key informants from five cities--Liverpool, Sandwell, Vienna, Pula, and Rijeka--by using a chain technique. Data on each intervention are collected through an in-depth interview with a program leader, the collection of project-related documents, and on-site observation. Qualitative analysis of data performed with content analysis and computer-assisted free-text analysis reveals different characteristics of interventions depending on whether they are initiated by the city government sector, health-care system, or citizens sector (independent of the city or country). The assessment of the efficiency of these three groups of interventions also differs because of varying features, scope (activity potentials) and impact they are able to accomplish. We have identified ways in which the efficiency of all three groups of interventions can be improved. The efficiency of the interventions within the city sector can be increased through an improved process of delegation to other sectors, higher involvement of user groups, and higher receptivity and organizational flexibility. The efficiency of the interventions within the citizens sector can be improved through professional, organizational, and financial support. Support from the professional community is important for citizens sector interventions in confirming the importance of the problem they address and legitimizing the actions they propose and undertake.

The role of U.S. public hospitals in urban health

Public hospitals in the United States play a key role in urban health. In many metropolitan communities, public hospitals maintain the health care safety net. Most urban public hospitals have evolved to not only provide care for the indigent but also to serve their communities in other ways, including serving as major providers for tertiary services such as trauma and those that support homeland security; serving as the foundation for primary care services; continuing to train a significant number of physician, nurses, and other medical personnel; and providing laboratories for clinical medical research. Federal budget cuts such as those in the Balanced Budget Act of 1997, recent state budget deficits, competition for Medicaid Managed Care, and the growth in the number of uninsured have led to a decline in revenues among urban public hospitals. To be better stewards of scarce resources, public hospitals have moved to reduce inpatient demand by adopting prevention strategies that are aimed at addressing the determinants of health, the complex interactions among social and economic factors, the physical environment, and individual behavior. These factors contribute to health status and offer opportunities to intervene and improve community health. Urban public hospitals, to be successful in the next stage of their evolution, need to learn to manage the "in-betweens"--partnering with governmental and nongovernmental entities to identify and work together on common health and safety issues. If public hospitals engage the community successfully, building trust and establishing new capability and capacity, urban public hospitals will survive, evolve, and continue their tradition of service.

Turning point sets the stage for emergency preparedness planning

Nearly a billion dollars were made available to state health departments through federal grants in the spring of 2002 for public health emergency preparedness plans. Twenty-one states had already been participating for some years in The Robert Wood Johnson Foundation's Turning Point Initiative. This article illustrates how earlier practice and experience in developing cross-sector collaborations and institutionalizing a model of broad-based partnerships for public health decision making can increase effectiveness and efficiency in responding to a call for action around an emergency.

US-style commissioning. Raising Arizona

Strategic health authorities can learn a lot about strategic vision from Arizona's healthcare cost containment system. The Arizona commissioners have greater power than primary care trusts to push through new and more effective models of community care. Commissioner/provider relations can be fraught as health plans hold out for big discounts.

The costs and benefits to participants in community partnerships: a paradox?

This article examines the degree of stakeholder participation in health and social partnership schemes in relation to their perceptions of benefits, costs, satisfaction, commitment, and ownership. The findings suggest that (a) involvement, commitment, and sense of ownership were invariably associated with high benefits and mostly with low costs; (b) benefits, commitment, and ownership might be more sensitive monitors of involvement than costs and satisfaction; (c) an increase in involvement was initially associated with decreased costs and increased satisfaction up to a point beyond which costs increased and satisfaction decreased despite increasing benefits; and (d) favorable cost-benefit ratios were perceived when the benefits were at least 1.6 times the costs. Partnership initiatives need to explore the involvement "cut-off" point at which the costs (and satisfaction) might change direction. For favorable cost-benefit ratios, benefits need to be at least 60% more than costs (Ansari's paradox).

The economic impact of several hospitals on their community

This study quantifies the value that several hospitals in a hospital system have on their local communities. Also included is an analysis of the types of value-added services and resources offered by the hospitals. The hospitals are assessed in 3 arenas: as an employer, as a major provider of healthcare services, and as a contributor to the quality of life of the region through the involvement of its employees in community services activities. The results indicate that the hospital system contributes almost dollars 1.7 billion (or 6.6%) toward the dollars 25 billion local economy.

Profitable gifts: a history of the Merck Mectizan donation program and its implications for international health

A unique public/private partnership situated around a pharmaceutical, Merck's Mectizan donation program stands out as an example of corporate philanthropy in the history of the pharmaceutical industry and provides insight into future public/private partnerships in public health. This paper considers the issues Merck faced in the decision to donate Mectizan (ivermectin) and in the subsequent development of the Mectizan donation program, delineating the moral and financial debates that arose within the company. Coming after almost 15 years of donation, this assessment of the program's strengths and shortcomings suggests how the pharmaceutical industry can better serve as a viable partner in improving international health.

Triad's new market strategy: a threat to community hospitals

Faced with unprecedented financial pressures, many nonprofit hospitals today contemplate hooking up with large corporations and converting to for-profit status. In the deals that result, the talk is largely about stock value and the interests of investors. The larger public-interest question of how the conversion will affect the health of community members often receives short shift. Most recently, Triad, an HCA spin-off, has emerged as a major player in the market for faltering nonprofits, zeroing in on institutions all the way from Alaska to North Carolina, and this has advocates worried, because the company can be singularly insensitive to community health care needs. But Triad is also remarkably adept at winning public favor. In this States of Health, we'll look at the broader public policy questions raised by such corporate health ventures, questions that point to the need for stronger oversight and regulatory mechanisms to assure that the public interest is protected in our increasingly market-driven health system.

Lessons Learned in Phase I of the Southern Rural Access Program

The Robert Wood Johnson Foundation's Southern Rural Access Program has been an important investment of philanthropic funds to augment resources and improve health care access in underserved rural communities. The program's first phase has taught important lessons about building capacity in rural health care. This article uses a variety of data to document the program's major accomplishments and most significant challenges to date. The program's revolving loan fund efforts are promising. The program has also played a catalytic role in stimulating rural health network development in the South and has helped stimulate partnerships with Southern philanthropies and multiple local, state, and federal agencies. Challenges have included the broad geographic and programmatic focus of the initiative as well as changing and often difficult state policy environments. Additional challenges include maintaining interagency coordination over time and managing staff and lead agency turnover. Overall, the experience suggests that a concentrated regional approach has merit.

Improving access to capital for health care infrastructure: the experience of the Southern Rural Access Program's revolving loan fund

Lack of access to affordable capital is a formidable barrier that compromises rural health care infrastructure development in poor rural areas. Commercial lending institutions are often limited in their ability to respond to those needs due to traditional lending criteria: creditworthiness, equity, management ability, experiences, and cash flow or profits. In the Southern Rural Access Program, a development model more frequently used in other sectors has been successfully applied to health care to help clear these hurdles. This paper describes the 5 operational loan funds in Arkansas, Louisiana, Mississippi, South Carolina, and West Virginia receiving support from the Southern Rural Access Program. Two models of loan funds have evolved: those led by health agencies and those led by community development finance institutions whose mission is rural economic development. This paper outlines major distinctive features of these 2 approaches and describes major implementation challenges these loan funds face. Key accomplishments are high-lighted, including the ability to leverage additional resources from state, federal, philanthropic, and private sources through these funds. These loan fund programs provide models for other states interested in improving access to capital to help build the rural health care infrastructure while making health care more economically viable through integration with other community development initiatives.

Connecting our resources: Louisiana's approach to community health network development

Louisiana's rural community health systems are in crisis because of pressures fueled by the rising costs of health care, sustained poor health status, state budget shortfalls and changes in priorities, and a sliding rural economy. The development of community health networks is providing new infrastructure and capacity for communities to reprioritize, formulate innovative partnerships, and leverage new resources. Successful elements of Louisiana's network development experience include community commitment to engage in study and action; the availability of capable and motivated technical assistance; an approach that involves open-engagement, community-driven decision-making; and data-driven problem definition, prioritization, and solutions. Louisiana's experiences illustrate the benefits of developing networks along with, or as a result of, a community health plan. When a community owns its health improvement plan, it is more likely to support the new network as a structure for implementation. Broad-scale participation is also a principle of success. When social service agencies are included along with health agencies, more comprehensive strategies result, and they bring additional resources, resulting in more holistic solutions. The cases of 2 networks are presented as illustrations. One involves the facilitation of a community planning process for an existing network. The plan helped to expand the network's community connections and support and provided the content for a successful application for a Health Resources and Services Administration Community Access Program grant. In the second case, a new network was developed, and it leveraged federal funds from the federal Office of Rural Health Policy's Network Development Grant Program.

Promoting safe walking and biking to school: the Marin County success story

Walking and biking to school can be an important part of a healthy lifestyle, yet most US children do not start their day with these activities. The Safe Routes to School Program in Marin County, California, is working to promote walking and biking to school. Using a multipronged approach, the program identifies and creates safe routes to schools and invites communitywide involvement. By its second year, the program was serving 4665 students in 15 schools. Participating public schools reported an increase in school trips made by walking (64%), biking (114%), and carpooling (91%) and a decrease in trips by private vehicles carrying only one student (39%).