Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer.

Multiple organizations around the world have issued evidence-based exercise guidance for patients with cancer and cancer survivors. Recently, the American College of Sports Medicine has updated its exercise guidance for cancer prevention as well as for the prevention and treatment of a variety of cancer health-related outcomes (eg, fatigue, anxiety, depression, function, and quality of life). Despite these guidelines, the majority of people living with and beyond cancer are not regularly physically active. Among the reasons for this is a lack of clarity on the part of those who work in oncology clinical settings of their role in assessing, advising, and referring patients to exercise. The authors propose using the American College of Sports Medicine's Exercise Is Medicine initiative to address this practice gap. The simple proposal is for clinicians to assess, advise, and refer patients to either home-based or community-based exercise or for further evaluation and intervention in outpatient rehabilitation. To do this will require care coordination with appropriate professionals as well as change in the behaviors of clinicians, patients, and those who deliver the rehabilitation and exercise programming. Behavior change is one of many challenges to enacting the proposed practice changes. Other implementation challenges include capacity for triage and referral, the need for a program registry, costs and compensation, and workforce development. In conclusion, there is a call to action for key stakeholders to create the infrastructure and cultural adaptations needed so that all people living with and beyond cancer can be as active as is possible for them.

The Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials in Mozambique, Pakistan, and India: an individual participant-level meta-analysis.

BACKGROUND: To overcome the three delays in triage, transport and treatment that underlie adverse pregnancy outcomes, we aimed to reduce all-cause adverse outcomes with community-level interventions targeting women with pregnancy hypertension in three low-income countries. METHODS: In this individual participant-level meta-analysis, we de-identified and pooled data from the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised controlled trials in Mozambique, Pakistan, and India, which were run in 2014-17. Consenting pregnant women, aged 12-49 years, were recruited in their homes. Clusters, defined by local administrative units, were randomly assigned (1:1) to intervention or control groups. The control groups continued local standard of care. The intervention comprised community engagement and existing community health worker-led mobile health-supported early detection, initial treatment, and hospital referral of women with hypertension. For this meta-analysis, as for the original studies, the primary outcome was a composite of maternal or perinatal outcome (either maternal, fetal, or neonatal death, or severe morbidity for the mother or baby), assessed by unmasked trial surveillance personnel. For this analysis, we included all consenting participants who were followed up with completed pregnancies at trial end. We analysed the outcome data with multilevel modelling and present data with the summary statistic of adjusted odds ratios (ORs) with 95% CIs (fixed effects for maternal age, parity, maternal education, and random effects for country and cluster). This meta-analysis is registered with PROSPERO, CRD42018102564. FINDINGS: Overall, 44 clusters (69 330 pregnant women) were randomly assigned to intervention (22 clusters [36 008 pregnancies]) or control (22 clusters [33 322 pregnancies]) groups. 32 290 (89·7%) pregnancies in the intervention group and 29 698 (89·1%) in the control group were followed up successfully. Median maternal age of included women was 26 years (IQR 22-30). In the intervention clusters, 6990 group and 16 691 home-based community engagement sessions and 138 347 community health worker-led visits to 20 819 (57·8%) of 36 008 women (of whom 11 095 [53·3%] had a visit every 4 weeks) occurred. Blood pressure and dipstick proteinuria were assessed per protocol. Few women were eligible for methyldopa for severe hypertension (181 [1%] of 20 819) or intramuscular magnesium sulfate for pre-eclampsia (198 [1%]), of whom most accepted treatment (162 [89·5%] of 181 for severe hypertension and 133 [67·2%] of 198 for pre-eclampsia). 1255 (6%) were referred to a comprehensive emergency obstetric care facility, of whom 864 (82%) accepted the referral. The primary outcome was similar in the intervention (7871 [24%] of 32 290 pregnancies) and control clusters (6516 [22%] of 29 698; adjusted OR 1·17, 95% CI 0·90-1·51; p=0·24). No intervention-related serious adverse events occurred, and few adverse effects occurred after in-community treatment with methyldopa (one [2%] of 51; India only) and none occurred after in-community treatment with magnesium sulfate or during transport to facility. INTERPRETATION: The CLIP intervention did not reduce adverse pregnancy outcomes. Future community-level interventions should expand the community health worker workforce, assess general (rather than condition-specific) messaging, and include health system strengthening. FUNDING: University of British Columbia, a grantee of the Bill & Melinda Gates Foundation.

Rebuilding a US Federal Data Strategy After the End of the "Community Health Status Indicators".

For nearly 2 decades, the Community Health Status Indicators tool reliably supplied communities with standardized, local health data and the capacity for peer-community comparisons. At the same time, it created a large community of users who shared learning in addressing local health needs. The tool survived a transition from the Health Resources and Services Administration to the Centers for Disease Control and Prevention before being shuttered in 2017. While new community data tools have come online, nothing has replaced Community Health Status Indicators, and many stakeholders continue to clamor for something new that will enable local health needs assessments, peer comparisons, and creation of a community of solutions. The National Committee on Vital and Health Statistics heard from many stakeholders that they still need a replacement data source. (Am J Public Health. 2021;111(10):1865-1873. https://doi.org/10.2105/AJPH.2021.306437).

Telehealth and the Community SMI Population: Reflections on the Disrupter Experience of COVID-19.

The novel coronavirus pandemic and the resulting expanded use of telemedicine have temporarily transformed community-based care for individuals with serious mental illness (SMI), challenging traditional treatment paradigms. We review the rapid regulatory and practice shifts that facilitated broad use of telemedicine, the literature on the use of telehealth and telemedicine for individuals with SMI supporting the feasibility/acceptability of mobile interventions, and the more limited evidence-based telemedicine practices for this population. We provide anecdotal reflections on the opportunities and challenges for telemedicine drawn from our daily experiences providing services and overseeing systems for this population during the pandemic. We conclude by proposing that a continued, more prominent role for telemedicine in the care of individuals with SMI be sustained in the post-coronavirus landscape, offering future directions for policy, technical assistance, training, and research to bring about this change.

Feasibility of task-sharing with community health workers for the identification, emergency management and referral of women with pre-eclampsia, in Mozambique.

BACKGROUND: Maternal mortality is an important public health problem in low-income countries. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. There is limited evidence on the role of community health workers in the management of pregnancy complications. This study aimed to describe the feasibility of task-sharing the initial screening and initiation of obstetric emergency care for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and document healthcare facility preparedness to respond to referrals. METHOD: The study took place in Maputo and Gaza Provinces in southern Mozambique and aimed to inform the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial. This was a mixed-methods study. The quantitative data was collected through self-administered questionnaires completed by community health workers and a health facility survey; this data was analysed using Stata v13. The qualitative data was collected through focus group discussions and in-depth interviews with various community groups, health care providers, and policymakers. All discussions were audio-recorded and transcribed verbatim prior to thematic analysis using QSR NVivo 10. Data collection was complemented by reviewing existing documents regarding maternal health and community health worker policies, guidelines, reports and manuals. RESULTS: Community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they have not been trained to manage obstetric emergencies. Furthermore, barriers at health facilities were identified, including lack of equipment, shortage of supervisors, and irregular drug availability. All primary and the majority of secondary-level facilities (57%) do not provide blood transfusions or have surgical capacity, and thus such cases must be referred to the tertiary-level. Although most healthcare facilities (96%) had access to an ambulance for referrals, no transport was available from the community to the healthcare facility. CONCLUSIONS: This study showed that task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia were deemed feasible and acceptable at the community-level, but an effort should be in place to address challenges at the health system level.

Maternal mortality is an important public health problem in Mozambique. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. We conducted a study to describe the feasibility of task-sharing the screening and initiation of management for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and to document healthcare facility preparedness to respond to referrals. The study was done to inform a future intervention trial known as the Community-Level Interventions for Pre-eclampsia (CLIP) study. We interviewed community health workers, women, various community groups, health care providers, and policymakers and assessed health facilities in Maputo and Gaza provinces, Mozambique. Our results showed that community health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they were not trained or equipped to provide obstetric emergencies care prior to referral. Nurses at primary health facilities were supportive of task-sharing with community health workers; however, some barriers mentioned include a lack of equipment, shortage of supervisors, and irregular drug availability. Local stakeholders emphasized the need for comprehensive training and supervision of community health workers to take on new tasks. Task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia was deemed feasible at the community level in southern Mozambique, but still, to be addressed some health system level barriers to the management of pregnancies complications.

Home- and Community-Based Provider Preparation for Pennsylvania's Managed Long-term Services and Supports.

As Pennsylvania implements its managed long-term services and supports program, we explore how home- and community-based providers are preparing for and perceiving the transition through an online survey. We summarize responses and conduct chi-square analysis to measure differences between select provider groups. Despite high levels of uncertainty about program impact, over 84% of respondents plan to participate. We found that providers in the first implementation phase had more strategic and operational discussions with MCOs than the other two phases (p < .03). As program rollout continues, we anticipate changes in MCO-provider conversation frequency and topics based upon implementation zone.

Comparison of Primary Care Experience in Hospital-Based Practices and Community-Based Office Practices in Japan.

PURPOSE: The quality of health care, including primary care, is influenced by the context in which care is delivered. We investigated the association between primary care practice location and patient experience with a focus on differences between hospital-based practices and community-based office practices. METHODS: We conducted a cross-sectional study in a primary care practice-based research network in Japan among 25 participating facilities: 6 small and medium-sized hospitals and 19 community-based offices. We assessed patient experience of primary care using a Japanese version of Primary Care Assessment Tool (JPCAT), which comprises 6 domains: first contact, longitudinality, coordination, comprehensiveness with respect to services available, comprehensiveness with respect to services provided, and community orientation. RESULTS: Analyses were based on 1,725 primary care patients. After adjustment for possible confounders and clustering within facilities, compared with community-based office practices, hospital-based practices were associated with poorer patient experience of community orientation (adjusted mean difference = -5.76; 95% CI, -10.35 to -1.17). In contrast, hospital-based practices were associated with comparatively better patient experience of first contact (adjusted mean difference = 15.43; 95% CI, 5.13 to 25.72). CONCLUSIONS: Our study elucidates differences in the strengths and challenges of primary care between hospital-based practices and community-based office practices, with a focus on patient centeredness. Improving community orientation in hospital-based practices and improving accessibility, including out-of-hours care, in community-based office practices may enhance the quality of primary care and promote standardization of care across settings.

High-risk medication in community care: a scoping review.

PURPOSE: To review the international literature related to high-risk medication (HRM) in community care, in order to (1) define a definition of HRM and (2) list the medication that is considered HRM in community care. METHODS: Scoping review: Five databases were systematically searched (MEDLINE, Scopus, CINAHL, Web Of Science, and Cochrane) and extended with a hand search of cited references. Two researchers reviewed the papers independently. All extracted definitions and lists of HRM were subjected to a self-developed quality appraisal. Data were extracted, analysed and summarised in tables. Critical attributes were extracted in order to analyse the definitions. RESULTS: Of the 109 papers retrieved, 36 met the inclusion criteria and were included in this review. Definitions for HRM in community care were used inconsistently among the papers, and various recurrent attributes of the concept HRM were used. Taking the recurrent attributes and the quality score of the definitions into account, the following definition could be derived: "High-risk medication are medications with an increased risk of significant harm to the patient. The consequences of this harm can be more serious than those with other medications". A total of 66 specific medications or categories were extracted from the papers. Opioids, insulin, warfarin, heparin, hypnotics and sedatives, chemotherapeutic agents (excluding hormonal agents), methotrexate and hypoglycaemic agents were the most common reported HRM in community care. CONCLUSION: The existing literature pertaining to HRM in community care was examined. The definitions and medicines reported as HRM in the literature are used inconsistently. We suggested a definition for more consistent use in future research and policy. Future research is needed to determine more precisely which definitions should be considered for HRM in community care.

"All boats will rise": Physicians' perspectives on multidisciplinary lung cancer care in a community-based hospital setting.

PURPOSE: We explored the perceived strengths, barriers to implementation, and suggestions for sustainable implementation of a multidisciplinary model within a community-based hospital system from the physicians' perspectives. METHODS: We conducted 9 focus groups with 37 physicians involved in the care of lung cancer patients. Grounded theory methodology guided the identification of recurrent themes that emerged from the qualitative data analysis. RESULTS: The majority of study participants agreed that the multidisciplinary model could benefit patients by promoting high quality, efficient, and well-coordinated care. Co-location, financial disincentives, and time constraints were identified as major deterrents to full participation in a multidisciplinary clinic. Other perceived challenges were the integration of a multidisciplinary care model into the existing healthcare system, maintenance of referral streams, and designation of the physician primarily responsible for a patient's care. Educating physicians about the availability of a multidisciplinary clinic, establishing efficient processes for initial consultations, implementing technology for virtual participation, and using a nurse navigator with reliable closed-loop communication were suggested to improve the implementation of the multidisciplinary model. CONCLUSIONS: Physicians generally agreed that the multidisciplinary model could improve lung cancer care, but they perceived significant personal, institutional, and system-level barriers that need to be addressed for its successful implementation in a community healthcare setting.

Can people-centered community-oriented interventions improve skilled birth attendance? Evidence from a quasi-experimental study in rural communities of Cambodia, Kenya, and Zambia.

BACKGROUND: Skilled attendance at delivery is a key marker for reducing maternal mortality. Effective community engagement strategies complemented by community health worker (CHW) services can improve access to maternal health services in areas with limited health infrastructure or workforce. METHODS: A quasi-experimental study with matched comparison groups was conducted in Cambodia, Kenya and Zambia to determine the effect of integrated community investments on skilled birth attendance (SBA). In each country, communities in two districts/sub-districts received a package of community-oriented interventions comprised of timed CHW household health promotion for maternal, newborn and child health complemented by social accountability mechanisms using community scorecards. Two matched comparison districts/sub-districts received ongoing routine interventions. Data from the final evaluation were examined to determine the effect of timed CHW services and community-oriented interventions on SBA. RESULTS: Over 80% of the 3037 women in Cambodia, 2805 women in Kenya and 1171 women in Zambia reported SBA. Women in intervention sites who received timely CHW health promotion and social accountability mechanisms in Cambodia showed significantly higher odds of SBA (aOR = 7.48; 95% CI: 3.87, 14.5). The findings also indicated that women over the age of 24 in Cambodia, women with primary or secondary education in Cambodia and secondary education in Kenya, women from higher wealth quintiles in Cambodia, and women with four or more antenatal care (ANC) visits in all countries reported significantly higher odds of SBA. Inclusion of family members in pregnancy-related discussions in Kenya (aOR = 2.12; 95% CI: 1.06, 4.26) and Zambia (aOR = 6.78; 95% CI: 1.15, 13.9) and follow up CHW visits after a referral or health facility visit (aOR = 2.44; 95% CI: 1.30, 4.60 in Cambodia; aOR = 2.17; 95% CI 1.25, 3.75 in Kenya; aOR = 1.89; 95% CI: 1.05, 2.02 in Zambia) also showed significantly greater odds of SBA. CONCLUSIONS: Enhancing people-centered care through culturally appropriate community-oriented strategies integrating timely CHW health promotion and social accountability mechanisms shows some evidence for improving SBA during delivery. These strategies can accelerate the achievement of the sustainable development goals for maternal child and newborn health.

Outpatient and community care for preventing pressure injuries in spinal cord injury. A qualitative study of service users' and providers' experience.

STUDY DESIGN: Qualitative exploratory study. OBJECTIVES: Pressure injuries (PIs) are a major secondary condition occurring after spinal cord injuries (SCI). Optimization of outpatient and community care may be a promising approach to better support community-dwelling individuals with SCI in preventing PIs. The aim of this study was to examine the experiences of individuals with SCI, family caregivers and health professionals (HPs) in using or providing outpatient and community services for early treatment and prevention of PIs in SCI. SETTING: Switzerland. METHODS: Semi-structured interviews with a sample of Swiss residents community-dwelling individuals with SCI (n = 20), family caregivers (n = 5) and HPs (n = 22) were analysed using thematic analysis. RESULTS: General practitioners (GPs), home care providers, SCI-specialized outpatient clinics and an SCI-specialized nursing service are involved in the prevention and early treatment of PIs. Our findings show that the needs of individuals with SCI are not fully met: outpatient and community care is often fragmented, mono-professional and non-specialized, while persons with SCI and HPs prefer coordinated, inter-professional and specialized services for preventing and treating PIs. Our findings also highlight the challenges faced by HPs in providing care to individuals with SCI in the community. CONCLUSIONS: Although there seems to be a gap in service provision, there is the potential for improvement by better integrating the different providers in a network and structuring their collaborations. Concrete suggestions are: systematizing knowledge transfer to home care providers and GPs; redefining the role of involved HPs and individuals with SCI and reinforcing the role of the SCI-specialized nursing service.

Context matters: a qualitative study of the practicalities and dilemmas of delivering integrated chronic care within primary and secondary care settings in a rural Malawian district.

BACKGROUND: With the increasing double burden of communicable and non-communicable diseases (NCDs) in sub-Saharan Africa, health systems require new approaches to organise and deliver services for patients requiring long-term care. There is increasing recognition of the need to integrate health services, with evidence supporting integration of HIV and NCD services through the reorganisation of health system inputs, across system levels. This study investigates current practices of delivering and implementing integrated care for chronically-ill patients in rural Malawi, focusing on the primary level. METHODS: A qualitative study on chronic care in Phalombe district conducted between April 2016 and May 2017, with a sub-analysis performed on the data following a document analysis to understand the policy context and how integration is conceptualised in Malawi; structured observations in five of the 15 district health facilities, selected purposively to represent different levels of care (primary and secondary), and ownership (private and public). Fifteen interviews with healthcare providers and managers, purposively selected from the above facilities. Meetings with five non-governmental organisations to study their projects and support towards chronic care in Phalombe. Data were analysed using a thematic approach and managed in NVivo. RESULTS: Our study found that, while policies supported integration of various disease-specific programmes at point of care, integration efforts on the ground were severely hampered by human and health resource challenges e.g. inadequate consultation rooms, erratic supplies especially for NCDs, and an overstretched health workforce. There were notable achievements, though most prominent at the secondary level e.g. the establishment of a combined NCD clinic, initiating NCD screening within HIV services, and initiatives for integrated information systems. CONCLUSION: In rural Malawi, major impediments to integrated care provision for chronically-ill patients include the frail state of primary healthcare services and sub-optimal NCD care at the lowest healthcare level. In pursuit of integrative strategies, opportunities lie in utilising and expanding community-based outreach strategies offering multi-disease screening and care with strong referral linkages; careful task delegation and role realignment among care teams supported with proper training and incentive mechanisms; and collaborative partnership between public and private sector actors to expand the resource-base and promoting cross-programme initiatives.

Implementing performance-based financing in peripheral health centres in Mali: what can we learn from it?

INTRODUCTION: Numerous sub-Saharan African countries have experimented with performance-based financing (PBF) with the goal of improving health system performance. To date, few articles have examined the implementation of this type of complex intervention in Francophone West Africa. This qualitative research aims to understand the process of implementing a PBF pilot project in Mali's Koulikoro region. METHOD: We conducted a contrasted multiple case study of performance in 12 community health centres in three districts. We collected 161 semi-structured interviews, 69 informal interviews and 96 non-participant observation sessions. Data collection and analysis were guided by the Consolidated Framework for Implementation Research adapted to the research topic and local context. RESULTS: Our analysis revealed that the internal context of the PBF implementation played a key role in the process. High-performing centres exercised leadership and commitment more strongly than low-performing ones. These two characteristics were associated with taking initiatives to promote PBF implementation and strengthening team spirit. Information regarding the intervention was best appropriated by qualified health professionals. However, the limited duration of the implementation did not allow for the emergence of networks or champions. The enthusiasm initially generated by PBF quickly dissipated, mainly due to delays in the implementation schedule and the payment modalities. CONCLUSION: PBF is a complex intervention in which many actors intervene in diverse contexts. The initial level of performance and the internal and external contexts of primary healthcare facilities influence the implementation of PBF. Future work in this area would benefit from an interdisciplinary approach combining public health and anthropology to better understand such an intervention. The deductive-inductive approach must be the stepping-stone of such a methodological approach.

Impact of Survivorship Care Plans and Planning on Breast, Colon, and Prostate Cancer Survivors in a Community Oncology Practice.

With a growing number of cancer survivors, survivorship care plans (SCPs) are recommended to communicate information about late effects of treatment and follow-up care. Community oncology practices follow 85% of adult cancer survivors but report more difficulty in providing SCPs compared to academic centers. Our objective was to evaluate the impact of delivering SCPs in a community oncology practice by examining awareness of SCP receipt as well as how provision affects survivors' perception of care quality and of their condition. Survivors who accepted a SCP as standard of care were recruited from a community oncology practice in the Midwest and completed surveys prior to SCP provision (baseline) and 4 weeks later (follow-up). Within-survivor changes in knowledge of SCP receipt, satisfaction and perceived care coordination were assessed. Thirty cancer survivors (breast, colon, and prostate) completed the baseline survey, while 24 completed the follow-up survey (80% response rate). Participants reported receiving SCPs and treatment summaries more frequently at follow-up after receiving a SCP. At follow-up, there was a significant increase in survivor activation and involvement in care along with satisfaction of knowledge of care. Communication about and during SCP provision may need to be clearer: 34% of survivors could not correctly identify SCP receipt in this study. This may place these survivors at a disadvantage, if this leads to less awareness of important information regarding follow-up surveillance and management. Of those aware of SCP receipt, SCP provision had positive impacts in this small, short-term study.

Using Ripple Effects Mapping to Evaluate a Community-Based Health Program: Perspectives of Program Implementers.

Traditional evaluation tools are oftentimes ill-suited for use in community settings where intervention outcomes of interest may occur at multiple levels and are influenced by interacting factors. Ripple effects mapping (REM) is a participatory technique engaging stakeholders to visually map project/program efforts and results to collect impact data. Using appreciative inquiry, the method helps participants and evaluators understand context for changes resulting from program experiences and is particularly well suited for community-based, participatory programs where impacts often occur beyond the individual level. This article describes the REM method and how it was applied to explore impact and refine program theory of the Extension Wellness Ambassador Program (EWAP), a community-based health-focused master volunteer program, from the perspective of program implementers (n = 10). Insights emerging from the REM session indicate EWAP promotes health behavior change, contributes to community development due to increased leadership capacity, and sustains and grows implementing organizations. The program theory shaping evaluation was refined to better capture impact beyond individual levels. Application of the REM method to a community health program demonstrates feasibility; health promotion practitioners should consider REM to understand program context and capture outcomes that typically evade measurement using traditional techniques.

A Qualitative Study of Community-Based HIV/AIDS Prevention Interventions, Programs, and Projects for Rural and Remote Regions in Canada: Implementation Challenges and Lessons Learned.

CONTEXT: Fifteen percent to 20% of the Canadian and American populations live outside urban areas, and despite growing regional HIV/AIDS-related health disparities, there is little published research specific to rural or remote (rural/remote) HIV/AIDS prevention programming. OBJECTIVE: To document implementation challenges, lessons learned, and evaluation approaches of promising and proven HIV/AIDS prevention programs and interventions developed and delivered by organizations with rural/remote catchment areas in Canada to provide a foundation for information sharing among agencies. DESIGN: Qualitative study design, using a community-based participatory research approach. We screened Canadian community-based organizations with an HIV/AIDS prevention mandate to determine whether they offered services for rural/remote populations and invited organizational representatives to participate in semistructured telephone interviews. Interviews were audio-recorded and transcribed. Content analysis was used to identify categories in the interview data. SETTING: Canada, provinces (all except Prince Edward Island), and territories (all except Nunavut). PARTICIPANTS: Twenty-four community-based organizations. RESULTS: Screening calls were completed with 74 organizations, of which 39 met study criteria. Twenty-four (62%) interviews were conducted. Populations most frequently served were Indigenous peoples (n = 13 organizations) and people who use drugs (n = 8 organizations) (categories not mutually exclusive). Key lessons learned included the importance of involving potential communities served in program development; prioritizing community allies/partnerships; building relationships; local relevancy and appropriateness; assessing community awareness or readiness; program flexibility/adaptability; and addressing stigma. Evaluation activities were varied and used for funder reporting and organizational learning. CONCLUSIONS: Rural/remote HIV/AIDS programs across Canada expressed similar challenges and lessons learned, suggesting that there is potential for knowledge exchange, and development of a community of practice. Top-down planning and evaluation models may fail to capture program achievements in rural/remote contexts. The long-term engagement practices that render rural/remote programs promising do not always conform to planning and implementation requirements of limited funding.

Evaluating the impact of community health volunteer home visits on child diarrhea and fever in the Volta Region, Ghana: A cluster-randomized controlled trial.

BACKGROUND: Although there is mounting evidence demonstrating beneficial effects of community health workers (CHWs), few studies have examined the impact of CHW programs focused on preventing infectious diseases in children through behavior changes. We assessed the preventive effects of community health volunteers (CHVs), who receive no financial incentive, on child diarrhea and fever prevalence in Ghana. METHODS AND FINDINGS: We conducted a cluster-randomized controlled trial in 40 communities in the Volta Region, Ghana. Twenty communities were randomly allocated to the intervention arm, and 20 to the control arm, using a computer-generated block randomization list. In the intervention arm, CHVs were deployed in their own community with the key task of conducting home visits for health education and community mobilization. The primary outcomes of the trial were diarrhea and fever prevalence at 6 and 12 months among under-5 children based on caregivers' recall. Secondary outcomes included oral rehydration treatment and rapid diagnostic testing for malaria among under-5 children, and family planning practices of caregivers. Generalized estimating equations (GEEs) with a log link and exchangeable correlation matrix were used to determine the relative risk (RR) and 95% confidence intervals (CIs) for diarrhea, fever, and secondary outcomes adjusted for clustering and stratification. Between April 18 and May 4, 2015, 1,956 children were recruited and followed up until September 20, 2016. At 6 and 12 months post-randomization, 1,660 (85%) and 1,609 (82%) participants, respectively, had outcomes assessed. CHVs' home visits had no statistically significant effect on diarrhea or fever prevalence at either time point. After a follow-up of 12 months, the prevalence of diarrhea and fever was 7.0% (55/784) and 18.4% (144/784), respectively, in the control communities and 4.5% (37/825) and 14.7% (121/825), respectively, in the intervention communities (12-month RR adjusted for clustering and stratification: diarrhea, RR 0.73, 95% CI 0.37-1.45, p = 0.37; fever, RR 0.76, 95% CI 0.51-1.14, p = 0.20). However, the following were observed: improved hand hygiene practices, increased utilization of insecticide-treated bed nets, and greater participation in community outreach programs (p-values < 0.05) in the intervention group. In a post hoc subgroup analysis, the prevalence of diarrhea and fever at 6 months was 3.2% (2/62) and 17.7% (11/62), respectively, in the intervention communities with ≥70% coverage and a ≥30-minute visit duration, and 14.4% (116/806) and 30.2% (243/806) in the control communities (RR adjusted for clustering, stratification, baseline prevalence, and covariates: diarrhea, RR 0.23, 95% CI 0.09-0.60, p = 0.003; fever, RR 0.69, 95% CI 0.52-0.92, p = 0.01). The main limitations were the following: We were unable to investigate the longer-term effects of CHVs; the trial may have been underpowered to detect small to moderate effects due to the large decline in diarrheal and fever prevalence in both the intervention and control group; and caregivers' practices were based on self-report, and the possibility of caregivers providing socially desirable responses cannot be excluded. CONCLUSIONS: We found no effect of CHVs' home visits on the prevalence of child diarrhea or fever. However, CHV programs with high community coverage and regular household contacts of effective duration may reduce childhood infectious disease prevalence. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Registry, ISRCTN49236178.

Diabetic foot ulcer incidence and survival with improved diabetic foot services: an 18-year study.

AIMS: To ascertain the effects of improvements in diabetic foot services over 18 years on incidence of diabetic foot ulceration. We also compared survival time from first ulcer development with presence of neuropathy, peripheral vascular disease, age and healing. METHODS: Persons with new ulceration and those at high risk of ulcer development were referred to community podiatry from 1998. Their details were recorded, with verbal consent, on a central database. The effects of neuropathy, peripheral vascular disease, healing and age on survival were analysed by Cox proportional hazards ratios. RESULTS: The incidence of first ulcer presentation decreased from 11.1 to 6.1 per 1000 persons between 2003 to 2017 (P <0.0001). Recurrent ulceration incidence remained stable. Prevalence of chronic and new foot ulceration combined increased from 20.7 to 33.1 per 1000 persons (P <0.0001). Ten-year survival was 85% for persons presenting with first ulcer and aged < 65 years, 50% for those aged 65-74 years and 25% for those aged 75-81 years (P < 0.0001). In those with peripheral vascular disease 5-year survival was 35% (P <0.001). CONCLUSIONS: Integrated care for the diabetic foot in one National Health Service (NHS) health service area over 18 years was associated with a reduction in first presentations of diabetic foot ulceration, but failed to reduce recurrent ulceration. Cumulative prevalence of all ulcers continues to increase. Monitoring ulceration incidence can inform audit and planning of diabetic foot care services. Survival is better than reported previously in persons < 65 years and in the absence of peripheral vascular disease.

Distribution of the EQ-5D-5L Profiles and Values in Three Patient Groups.

BACKGROUND: The distribution of EQ-5D-3L values (health state profiles, weighted by value sets) often shows two distinct groups, arising from both the distribution of profiles and the characteristics of value sets. To date, there is little evidence about the distribution of EQ-5D-5L values. OBJECTIVES: To explore the distribution of EQ-5D-5L profiles; to compare the distributions of EQ-5D-5L values arising from the English value set (EVS) and a 'mapped' value set (MVS); and to develop further the methods used to investigate clustering within EQ-5D data. METHODS: We obtained data from Cambridgeshire Community Services NHS Trust containing EQ-5D-5L profiles before treatment for three patient groups: community rehabilitation (N=6919); musculoskeletal physiotherapy (N=19999); and specialist nursing services (N=3366). Values were calculated using the EVS and MVS. Clusters were examined using the k-means method and Calinski-Harabasz pseudo-F index stopping rule. RESULTS: We found no evidence for clustering of EQ-5D-5L values arising from the classification system and no strong or consistent evidence of clustering arising from the EVS. There was clearer evidence of clustering using the MVS, with two being the optimal number of clusters. The clusters that were found for the EVS were very different from the MVS clusters. CONCLUSIONS: Unlike the EQ-5D-3L, clustering of EQ-5D-5L values does not seem to be driven by clustering of its profile. This suggests the EQ-5D-5L is superior in that it is less likely to generate artefactual clusters - however, clusters may still result from using value sets such as MVS that have the tendency to generate them.

Enabling Community Health Worker Recognition and Referral of Surgical Diseases: Pilot Study Results of a Pictorial Guide.

BACKGROUND: Access to surgical care is a pressing challenge, particularly for vulnerable populations. Informal and formal community health workers (CHWs), including lay people, increasingly function in pivotal roles in primary care, however, remain disconnected from surgical care in most environments. This study examined the degree to which CHW understanding of surgical conditions could be improved through the use of a pictorially based manual. METHODS: A manual and associated situational problem-solving questionnaire instrument were developed and contextualized through focus groups in Central America. A baseline assessment was obtained. In the program implementation, cohorts of formal and informal CHWs were introduced and trained to use the manual through a short curriculum. Assessment was repeated in program implementation, first with access to relevant manual content only, and then after the teaching session. Participants were also surveyed about manual scheme, usability, and utility. RESULTS: A total of 100 subjects (67% female) participated in baseline assessment, and 403 subjects (68% female) were assessed through the program implementation. Baseline problem-solving averaged 11.8 (SD 2.46) out of a possible 20 points. Mean score increased to 15.4 (SD 3.10) when participants had access to relevant surgical manual content and again to 15.9 (SD 3.09, p < 0.0001) following participation with an instructive curriculum. Participant score while utilizing the manual correlated with amount of education completed (r = 0.26), but baseline score did not. High readability 389 (96%) and high self-reported willingness for use 398 (96%) were noted. CONCLUSION: Baseline familiarity with surgically treatable conditions appears modest among rural Central American populations, and improves with access to a contextualized, pictorial manual focused on recognizing and appropriately referring surgical conditions.