Evaluating Lung Cancer Screening Across Diverse Healthcare Systems: A Process Model from the Lung PROSPR Consortium.

Numerous organizations, including the United States Preventive Services Task Force, recommend annual lung cancer screening (LCS) with low-dose CT for high risk adults who meet specific criteria. Despite recommendations and national coverage for screening eligible adults through the Centers for Medicare and Medicaid Services, LCS uptake in the United States remains low (<4%). In recognition of the need to improve and understand LCS across the population, as part of the larger Population-based Research to Optimize the Screening PRocess (PROSPR) consortium, the NCI (Bethesda, MD) funded the Lung PROSPR Research Consortium consisting of five diverse healthcare systems in Colorado, Hawaii, Michigan, Pennsylvania, and Wisconsin. Using various methods and data sources, the center aims to examine utilization and outcomes of LCS across diverse populations, and assess how variations in the implementation of LCS programs shape outcomes across the screening process. This commentary presents the PROSPR LCS process model, which outlines the interrelated steps needed to complete the screening process from risk assessment to treatment. In addition to guiding planned projects within the Lung PROSPR Research Consortium, this model provides insights on the complex steps needed to implement, evaluate, and improve LCS outcomes in community practice.

Population-based study in a rural area: methodology and challenges.

OBJECTIVE: To describe the planning, sampling, operational aspects of the field, and the sample obtained during a research conducted in a rural area, specifying and discussing the main logistical difficulties unique to these places and the solutions adopted. METHODS: We carried out a population-based, cross-sectional survey between January and June 2016, with a representative sample of the population aged 18 years or over living in the rural area of Pelotas (approximately 22,000 individuals), State of Rio Grande do Sul, Brazil. We collected demographic, socioeconomic, and health-related information, such as alcohol consumption, cigarette consumption, depressive symptoms, quality of diet, quality of life, physical activity, satisfaction with the health unit, overweight or obesity, and sleep problems. RESULTS: In the 720 domiciles sampled, 1,697 individuals were identified and 1,519 were interviewed (89.5%). The study initially drew 24 census tracts and proposed the visit to 42 households per tract; however, we need to adjust the method, such as decreasing the number of households per census tract (from 42 to 30) and identifying housing centers in each tract. The main reasons for these changes were difficulty accessing the area, large distances between households, misconceptions in the satellite data available (which did not fit the reality), and high cost of the field work. CONCLUSIONS: The previous detailed recognition of the research environment was crucial for decision making as the maps and territory had geographical inconsistencies. The strategies and techniques used in studies for the urban area are not applicable to the rural area given the outcomes observed in Pelotas. The decisions taken, keeping the methodological rigor, were essential to ensure the timely execution of the study with the financial resources available.

Community-Informed Health Promotion to Improve Health Behaviors in Honduras.

BACKGROUND: Honduras is the second poorest country in Central America. The already high burden of disease is disproportionately worse among individuals with less education and limited access to health care. Community engagement is needed to bridge the gap in health care resources with the need for health promotion and education. Culturally relevant health promotion activities can foster transcultural partnerships. PURPOSE: The purpose of this study was to partner nursing students with village leaders to assess a community's health needs and implement health promotion activities in Honduras. DESIGN: Participatory action research was used in the study. METHOD: U.S. nursing students ( n = 4) partnered with a nonprofit organization and community partners in Villa Soleada to interview mothers in Villa Soleada, a Honduran village of 44 families, and implement health promotion activities targeted to the health priorities of their families. RESULTS: Structured interviews with 24 mothers identified gastrointestinal issues, health care access and quality, and malaria as the top three priorities. Ninety-two percent of respondents were interested in nurse-led health promotion. Activities engaged new community partners. DISCUSSION: This partnership and learning model was well received and sustainable. The U.S. nurses involved in the partnership gained exposure to Honduran health issues and led locally tailored health promotions in Villa Soleada. The community's response to health promotion were positive and future activities were planned. IMPLICATIONS: Nursing student's immersion experiences to support population-based health activities in low-resource settings are a replicable model that can help build healthier communities with a sustainable local infrastructure. Transcultural nursing experiences enhance students' perspectives, increase personal and professional development, strengthen nursing students' critical thinking skills, and for some students, confirm their desire to practice in an international arena.

Population-based study in a rural area: methodology and challenges / Estudo de base populacional na zona rural: metodologia e desafios

ABSTRACT OBJECTIVE To describe the planning, sampling, operational aspects of the field, and the sample obtained during a research conducted in a rural area, specifying and discussing the main logistical difficulties unique to these places and the solutions adopted. METHODS We carried out a population-based, cross-sectional survey between January and June 2016, with a representative sample of the population aged 18 years or over living in the rural area of Pelotas (approximately 22,000 individuals), State of Rio Grande do Sul, Brazil. We collected demographic, socioeconomic, and health-related information, such as alcohol consumption, cigarette consumption, depressive symptoms, quality of diet, quality of life, physical activity, satisfaction with the health unit, overweight or obesity, and sleep problems. RESULTS In the 720 domiciles sampled, 1,697 individuals were identified and 1,519 were interviewed (89.5%). The study initially drew 24 census tracts and proposed the visit to 42 households per tract; however, we need to adjust the method, such as decreasing the number of households per census tract (from 42 to 30) and identifying housing centers in each tract. The main reasons for these changes were difficulty accessing the area, large distances between households, misconceptions in the satellite data available (which did not fit the reality), and high cost of the field work. CONCLUSIONS The previous detailed recognition of the research environment was crucial for decision making as the maps and territory had geographical inconsistencies. The strategies and techniques used in studies for the urban area are not applicable to the rural area given the outcomes observed in Pelotas. The decisions taken, keeping the methodological rigor, were essential to ensure the timely execution of the study with the financial resources available.

RESUMO OBJETIVO Descrever o planejamento, a amostragem, os aspectos operacionais do campo e a amostra obtida durante pesquisa realizada na zona rural, especificando e discutindo as principais dificuldades logísticas peculiares a esses locais e as soluções adotadas. MÉTODOS Entre janeiro e junho de 2016, foi realizado inquérito transversal de base populacional, com amostra representativa da população com 18 anos de idade ou mais residente na zona rural de Pelotas (cerca de 22 mil), RS, Brasil. Foram coletadas informações demográficas, socioeconômicas e relacionadas à saúde, como consumo de bebidas alcoólicas, consumo de cigarros, sintomas depressivos, qualidade da alimentação, qualidade de vida, atividade física, satisfação com a unidade de saúde, excesso de peso ou obesidade e problemas do sono. RESULTADOS Em 720 domicílios amostrados, 1.697 indivíduos foram identificados e 1.519 foram entrevistados (89,5%). O estudo, inicialmente, sorteou 24 setores e propôs-se a visitar 42 domicílios/setor, mas foram necessárias adequações metodológicas, especialmente a redução do número de domicílios por setor (de 42 para 30) e a identificação de núcleos habitacionais nos setores. As principais razões para as adequações foram dificuldade de acesso aos locais, grandes distâncias entre residências, equívocos nos dados geográficos disponíveis via satélite (não condiziam com a realidade) e alto custo. CONCLUSÕES O prévio reconhecimento detalhado do ambiente de pesquisa foi fundamental para a tomada de decisão perante às inconsistências geográficas entre mapas e território. As estratégias e técnicas dos estudos na zona urbana não são aplicáveis à zona rural no que tange ao contexto observado em Pelotas. As medidas adotadas, mantendo o rigor metodológico, foram fundamentais para garantir a execução do estudo no tempo planejado e com os recursos financeiros disponíveis.

Pediatric Oncology Clinic Care Model: Achieving Better Continuity of Care for Patients in a Medium-sized Program.

Providing the best care in both the inpatient and outpatient settings to pediatric oncology patients is all programs goal. Using continuous improvement methodologies, we changed from a solely team-based physician care model to a hybrid model. All patients were assigned a dedicated oncologist. There would then be 2 types of weeks of outpatient clinical service. A "Doc of the Day" week where each oncologist would have a specific day in clinic when their assigned patients would be scheduled, and then a "Doc of the Week" week where one physician would cover clinic for the week. Patient satisfaction surveys done before and 14 months after changing the model of care showed that patients were very satisfied with the care they received in both models. A questionnaire to staff 14 months after changing showed that the biggest effect was increased continuity of care, followed by more efficient clinic workflow and increased consistency of care. Staff felt it provided better planning and delivery of care. A hybrid model of care with a primary physician for each patient and assigned clinic days, alternating with weeks of single physician coverage is a feasible model of care for a medium-sized pediatric oncology program.

A population-based analysis of use and outcomes of laparoscopic bariatric surgery across socioeconomic groups in Taiwan.

BACKGROUND: With the growing development of minimally invasive techniques for the treatment of morbid obesity, laparoscopic bariatric surgery (LBS) is increasingly performed. This study aimed to assess the association between patients' socioeconomic status (SES) and the likelihood of undergoing LBS and related outcomes in Taiwan. METHODS: This nationwide population-based study was conducted by using data from Taiwan's National Health Insurance Research Database. A total of 3678 morbidly obese patients aged 18 years and older who underwent conventional open bariatric surgery or LBS were identified between 2004 and 2011. Regression analyses were performed using generalized estimating equation (GEE) models to account for the nesting of patients within physician to assess patients' SES category associated with the use of LBS and related outcomes. Odds ratios (ORs) and 95 % confidence intervals (CIs) were estimated. RESULTS: Compared with those with medium and low SES (84.6 % and 80.2 %), patients with high SES (88.1 %) had the highest percentage of undergoing LBS (P < 0.001). After adjusting for patient demographics, institution and surgeon characteristics, the multivariate GEE analysis revealed that the highest likelihood of undergoing LBS was noted in morbidly obese patients with high SES (OR = 1.45, 95 % CI 1.10-1.90), followed by those with medium SES (OR = 1.27, 95 % CI 1.04-1.56). In addition, patients with high SES had slightly lower length of hospital stay (LOS; OR = 0.90, 95 % CI 0.82-0.99) and hospital treatment cost (OR = 0.93, 95 % CI 0.87-0.99) than their counterparts after adjustment. CONCLUSIONS: The increased likelihood of undergoing LBS and lower LOS and hospital treatment cost were noted among morbidly obese patients with higher SES. This finding suggests there is the need to improve clinical practice and reduce health disparities in the surgical treatment of morbidly obese patients.

Gestão participativa no distrito sanitário especial indígena Cuiabá: uma análise de sua viabilidade política / Participatory management in the Special Indigenous Sanitary District Cuiabá an analysis of its political viability

Este trabalho se inscreve no campo da saúde pública em sua perspectiva interdisciplinar, pois mobiliza conhecimentos oriundos da epidemiologia, do planejamento e das ciências humanas e sociais. Nosso objetivo central foi analisar a viabilidade política do planejamento participativo na Terra Indígena Tirecatinga, DSEI Cuiabá, Estado de Mato Grosso, Brasil. A fundamentação teórica utilizada foi a Teoria do Jogo Social de Carlos Matus que visita e amplia duas outras teorias formuladas pelo autor: a Teoria das Situações e a Teoria da Produção Social. A estratégia metodológica escolhida foi o Estudo de Caso tendo em vista que a formulação de um plano local por meio do planejamento estratégico situacional tratou-se de um caso não significando que o processo e os resultados obtidos poderão ser generalizados para as demais comunidades indígenas do território nacional. Os depoimentos foram submetidos à Análise do Discurso segundo hipóteses de Dominique Mainguenau. Esperamos que o exercício do planejamento em território indígena amplie a compreensão da situação de saúde dos índios que vivem na Terra Indígena Tirecatinga, território adstrito ao DSEI Cuiabá; estenda a compreensão sobre as lógicas de ação que permeiam as práticas dos sujeitos nos espaços de participação social; que o planejamento seja um instrumento de reflexão e mudança para a organização fornecendo subsídios para a institucionalização do mesmo tendo em vista as necessidades dos sujeitos e, sobretudo, promova a

This work falls within the field of public health from an interdisciplinary perspective as it mobilizes knowledge from epidemiology, planning and human and social sciences. Our main objective was to analyze the political viability of participatory planning within Tirecatinga Indigenous Territory, DSEI Cuiaba, Mato Grosso, Brazil. The theoretical framework used was the Theory of Social Game by Carlos Matus, created by visiting and extending two other theories formulated by the same author: the Theory of Situations and the Theory of Social Production. The selected methodological strategy was a case study with a view to formulate a local level situational strategic planning used to treat a case. Therefore the process and the results cannot be generalised to other indigenous communities within the national territory. All reports were submitted to Discourse Analysis according to Dominique Mainguenaus hypothesis. We hope that the exercise of planning within indigenous territories can expand the understanding of the health status of Indians living within Tirecatinga Indigenous Territorry, a territory attached to the DSEI Cuiabá; extend the understanding of the logic of action that permeates the practices of the subjects in the spaces of social participation; that planning can be used as a reflection tool and promote changes to the organization providing support for the institutionalization from a perspective which recognizes the needs of individuals and, above all, promote

Opportunity meets planning: an assessment of the physical activity emphasis in state obesity-related plans.

BACKGROUND: In the United States, health promotion efforts often begin with state-level strategic plans. Many states have obesity, nutrition, or other topic-related plans that include physical activity (PA). The purpose of this study was to assess PA content in these state plans and make recommendations for future plan development. METHODS: Publically available plans were collected in 2010. A content analysis tool was developed based on the United States National PA Plan and included contextual information and plan content. All plans were double coded for reliability and analyzed using SPSS. RESULTS: Forty-three states had a statewide plan adopted between 2002 and 2010, none of which focused solely on PA. Over 80% of PA-specific strategies included policy or environmental changes. Most plans also included traditional strategies to increase PA (eg, physical education, worksite). Few plans included a specific focus on land use/community design, parks/recreation, or transportation. Less than one-half of plans included transportation or land use/community design partners in plan development. CONCLUSIONS: Though the majority of states had a PA-oriented plan, comprehensiveness varied by state. Most plans lacked overarching objectives on the built environment, transportation, and land use/community design. Opportunities exist for plan revision and alignment with the National PA Plan sectors and strategies.

Internship training adequately prepares South African medical graduates for community service - with exceptions.

BACKGROUND: The 2-year internship period for medical graduates began in South Africa in 2005 and has never been formally evaluated. OBJECTIVE: This study assessed the perceptions of community service medical officers (COSMOs) working at district hospitals (DHs) in KwaZulu-Natal (KZN) to determine whether the 2-year internship programme had adequately prepared them for community service (CS). METHOD: A cross-sectional descriptive study was conducted regarding the perceptions of COSMOs working at 22 district hospitals in KZN. Data were collected in July 2012, using a questionnaire based on the core skills and knowledge detailed in the Health Professions Council of South Africa intern log book. All eight domains were self-assessed and a score of 4 out of 5 indicated an ability to work independently. RESULTS: Of the COSMOs, 78% (60 out of 89) completed the questionnaire. Most felt well-prepared for CS in all disciplines, but critical gaps in knowledge and skills were identified in paediatrics, orthopaedics, anaesthetics and obstetrics. In addition, 75% of respondents (45 out of 60) expressed a need for additional training in the disciplines of ear, nose and throat (ENT), urology, ophthalmology and dermatology. CONCLUSION: The 2-year internship has provided the basis for independent medical practice in DHs. However, certain critical skill gaps need urgent attention, particularly in obstetrics and anaesthesia. Areas of weakness in ENT, urology, ophthalmology and dermatology could be addressed by including these specialities as a compulsory rotation in surgery, medicine or family medicine during internship training.

Governança, sustentabilidade e equidade no plano de saúde de São José dos Pinhais, Brasil / Governance, sustainability, and equity in the health program for the municipality of São José dos Pinhais, Brazil

OBJETIVO: Analisar o Relatório Final da VIII Conferência de Saúde e o Plano Municipal de Saúde de São José dos Pinhais 2010-2013 e verificar se esses documentos contemplaram os temas sustentabilidade, governança e equidade e as interfaces entre esses temas - políticas de governo e estado, balanço de poder e processo inclusivo e resultados impactantes -, que compõem um Modelo Conceitual para Desenvolvimento Humano e Promoção da Saúde proposto pelos autores. MÉTODOS: Neste estudo de caso, foram analisadas as 331 propostas aprovadas para incorporação no Plano Municipal de Saúde. Foram analisadas as seis categorias temáticas do Modelo Conceitual para Desenvolvimento Humano e Promoção da Saúde pelo programa ATLAS Ti 5.0. As propostas foram classificadas pelo número de temas e interfaces do Modelo Conceitual: propostas plenas de promoção de saúde continham as seis categorias de conceitos e interfaces; propostas de promoção parcial continham três categorias; e propostas incipientes continham uma categoria. RESULTADOS: Das 331 propostas aprovadas, 162 (49%) contemplaram as seis categorias temáticas, sendo classificadas como propostas plenas de promoção da saúde. Noventa e cinco (29%) contemplaram três categorias, sendo classificadas como de parcial promoção da saúde. Dessas, 38 (12%) contemplaram as categorias governança, sustentabilidade e políticas de governo/estado, 33 (10%) contemplaram governança, balanço de poder e equidade e 24 (7%) contemplaram equidade, processo inclusivo/resultados impactantes e sustentabilidade. Finalmente, 74 (22%) propostas contemplaram uma categoria, sendo classificadas como proposta de incipiente promoção da saúde: 36 (11%) contemplaram governança, 27 (8%) contemplaram sustentabilidade e 11 (3%) contemplaram equidade. CONCLUSÕES: Tendo em vista que 49% das propostas foram classificadas como de promoção plena da saúde, o controle social, a partir da participação popular na construção do plano de saúde, contribuiu para a promoção da saúde no município.

OBJECTIVE: To analyze the Final Report of the VIII Health Conference and the São José dos Pinhais City Health Program for 2010-2013 and investigate whether these documents addressed the themes of sustainability, governance, and equity and the interfaces between these themes-government policies, power balance, and inclusive processes/impacting results-that make up the Concept Model for Human Development and Health Promotion developed by the authors. METHOD: This case study analyzed 331 proposals approved for incorporation in the City Health Program. The six thematical categories of the Concept Model were analyzed using ATLAS Ti 5.0 software. The proposals were classified according to the number of themes and interfaces of the Concept Model: full health proposals contained all six categories; partial proposals contained three categories; and incipient proposals contained one category. RESULTS: Of 331 proposals approved, 162 (49%) contemplated the six thematical categories and were classified as full health promotion proposals. Ninety-five (29%) contemplated three categories (partial health promotion). Of these, 38 (12%) addressed Governance, Sustainability, and Government Policies, 33 (10%) addressed Governance, Power Balance, and Equity and 24 (7%) addressed Equity, Inclusive Processes/Impact Results, and Sustainability. Finally, 74 (22%) proposals contemplated only one category and were classified as incipient: 36 (11%) addressed Governance, 27 (8%) addressed sustainability, and 11 (3%) addressed equity. CONCLUSIONS: Based on the fact that 49% of the proposals approved were classified as full health promotion, it is considered that the effectiveness of social control and popular participation in the construction of health policies at the local level contritute to the promotion of health in the city.

An update on tobacco control initiatives in comprehensive cancer control plans.

INTRODUCTION: Comprehensive cancer control (CCC) coalitions address tobacco use, the leading cause of preventable death in the United States, through formal plans to guide tobacco control activities and other cancer prevention strategies. Best Practices for Comprehensive Tobacco Control Programs (Best Practices) and The Guide to Community Preventive Services (The Community Guide) are used to assist with this effort. We examined CCC plans to determine the extent to which they followed the Centers for Disease Control and Prevention's (CDC's) tobacco control and funding recommendations. METHODS: We obtained 69 CCC plans, current as of August 1, 2011, to determine which CDC recommendations from Best Practices and The Community Guide were incorporated. Data were abstracted through a content review and key word search and then summarized across the plans with dichotomous indicators. Additionally, we analyzed plans for inclusion of tobacco control funding goals and strategies. RESULTS: CCC plans incorporated a mean 4.5 (standard deviation [SD], 2.1) of 5 recommendations from Best Practices and 5.2 (SD, 0.9) of 10 recommendations from The Community Guide. Two-thirds of plans (66.7%) addressed funding for tobacco control as a strategy or action item; 47.8% of those plans (31.9% of total) defined a specific, measurable funding goal. CONCLUSION: Although most CCC plans follow CDC-recommended tobacco control recommendations and funding levels, not all recommendations are addressed by every plan and certain recommendations are addressed in varying numbers of plans. Clearer prioritization of tobacco control recommendations by CDC may improve the extent to which they are followed and therefore maximize their public health benefit.

The RSPH Health Promotion and Community Well-Being Organization and Partnership Awards.

The Royal Society for Public Health (RSPH) has launched the Health Promotion and Community Well-Being Organization and Partnership Awards, in collaboration with the Faculty of Public Health, the UK Public Health Register and the Institute of Health Promotion and Education. The Awards demonstrate the new Society's mission of "vision, voice and practice", and will raise the profile of health promotion in the UK and recognize good practice through public and professional acknowledgement. They are linked to a wider programme of advocacy and workforce development led by the RSPH through the Shaping the Future collaboration (see http://www.specialisedhealthpromotion.org.uk). The Awards have a powerful pedigree in the "settings" approach of the World Health Organization, and focus on the strong processes that organizations and partnerships need to develop and implement strategies. The Awards have been developed in partnership with four initial applicants from primary care trusts, and one partnership applicant spanning a primary care trust, local authority and Council for Voluntary Services. Assessment of applications is through peer review and a panel challenge. Examples of evidence from the five initial applicants, and how they relate to the criteria for the Awards, are showcased in this article. They are: Sefton's Health-Promoting Settings Network; the North East Essex Youth Health Trainers scheme; Health Equity Audits in Rotherham; public engagement in North Lancashire; and Health at Work in Plymouth.

Healthcare organizations, linguistic communities, and the emblematic model of palliative care

The linguistic-communicative paradigm offers some interesting perspectives in a context where the perception of patient needs is considered a critical step in high-quality care. This study describes healthcare organizations as linguistic communities based on the conceptual framework of Habermas' communicative action theory. Four communicative models are present in healthcare settings: objectifying-instrumental (hegemonic model), where elements of interaction are objectified for clinical purposes; dialogic model with strategic perspectives, in which conversations are used unilaterally as tools to access subjective states; non-dialogic-transmissional model, in which linguistic exchanges are replaced with artifacts to transmit information; and full communicative model (present in palliative care based in homecare and informal caregivers, emphasizing health team/family interactions). Based on these premises, we considered palliative care an emblematic communicative model based on multidisciplinary teams devoted to transdisciplinary collaboration. In these settings, linguistic interaction with patients and their families could provide a solid basis for organization of healthcare networks.

O paradigma lingüístico-comunicativo tem a oferecer perspectivas interessantes em um contexto no qual a percepção das necessidades dos pacientes é tida como um passo essencial à humanização da assistência. O presente estudo descreve as organizações de saúde como comunidades lingüísticas com base no marco conceitual da teoria da ação comunicativa de Habermas. No contexto assistencial estão presentes quatro modelos comunicativos: objetivador-instrumental (modelo hegemônico), no qual elementos da interação são objetificados em vista de propósitos clínicos; dialógico com perspectivas estratégicas, no qual as conversações são utilizadas unilateralmente como ferramentas para obter acesso a estados subjetivos; adialógico-transmissional, no qual as trocas lingüísticas são substituídas por artefatos para transmissão de informações; comunicativo pleno, presente nos cuidados paliativos organizados ao redor da assistência domiciliar e dos cuidadores informais, enfatizando a interação entre equipes de saúde e familiares. Com base em tais premissas, consideramos os cuidados paliativos como modelos comunicativos emblemáticos porque fundamentados em times multidisciplinares dedicados à mútua colaboração transdisciplinar. Nesse cenário, a interação lingüística com pacientes e seus familiares serviria como base estruturante das equipes assistenciais.

Healthcare organizations, linguistic communities, and the emblematic model of palliative care.

The linguistic-communicative paradigm offers some interesting perspectives in a context where the perception of patient needs is considered a critical step in high-quality care. This study describes healthcare organizations as linguistic communities based on the conceptual framework of Habermas' communicative action theory. Four communicative models are present in healthcare settings: objectifying-instrumental (hegemonic model), where elements of interaction are objectified for clinical purposes; dialogic model with strategic perspectives, in which conversations are used unilaterally as tools to access subjective states; non-dialogic-transmissional model, in which linguistic exchanges are replaced with artifacts to transmit information; and full communicative model (present in palliative care based in homecare and informal caregivers, emphasizing health team/family interactions). Based on these premises, we considered palliative care an emblematic communicative model based on multidisciplinary teams devoted to transdisciplinary collaboration. In these settings, linguistic interaction with patients and their families could provide a solid basis for organization of healthcare networks.

Control of human parasitic diseases: Context and overview.

The control of parasitic diseases of humans has been undertaken since the aetiology and natural history of the infections was recognized and the deleterious effects on human health and well-being appreciated by policy makers, medical practitioners and public health specialists. However, while some parasitic infections such as malaria have proved difficult to control, as defined by a sustained reduction in incidence, others, particularly helminth infections can be effectively controlled. The different approaches to control from diagnosis, to treatment and cure of the clinically sick patient, to control the transmission within the community by preventative chemotherapy and vector control are outlined. The concepts of eradication, elimination and control are defined and examples of success summarized. Overviews of the health policy and financing environment in which programmes to control or eliminate parasitic diseases are positioned and the development of public-private partnerships as vehicles for product development or access to drugs for parasite disease control are discussed. Failure to sustain control of parasites may be due to development of drug resistance or the failure to implement proven strategies as a result of decreased resources within the health system, decentralization of health management through health-sector reform and the lack of financial and human resources in settings where per capita government expenditure on health may be less than $US 5 per year. However, success has been achieved in several large-scale programmes through sustained national government investment and/or committed donor support. It is also widely accepted that the level of investment in drug development for the parasitic diseases of poor populations is an unattractive option for pharmaceutical companies. The development of partnerships to specifically address this need provides some hope that the intractable problems of the treatment regimens for the trypanosomiases and leishmaniases can be solved in the not too distant future. However, it will be difficult to implement and sustain such interventions in fragile health services often in settings where resources are limited but also in unstable, conflict-affected or post-conflict countries. Emphasis is placed on the importance of co-endemicity and polyparasitism and the opportunity to control parasites susceptible to cost-effective and proven chemotherapeutic interventions for a package of diseases which can be implemented at low cost and which would benefit the poorest and most marginalized groups. The ecology of parasitic diseases is discussed in the context of changing ecology, environment, sociopolitical developments and climate change. These drivers of global change will affect the epidemiology of parasites over the coming decades, while in many of the most endemic and impoverished countries parasitic infections will be accorded lower priority as resourced stressed health systems cope with the burden of the higher-profile killing diseases viz., HIV/AIDS, TB and malaria. There is a need for more holistic thinking about the interactions between parasites and other infections. It is clear that as the prevalence and awareness of HIV has increased, there is a growing recognition of a host of complex interactions that determine disease outcome in individual patients. The competition for resources in the health as well as other social sectors will be a continuing challenge; effective parasite control will be dependent on how such resources are accessed and deployed to effectively address well-defined problems some of which are readily amenable to successful interventions with proven methods. In the health sector, the problems of the HIV/AIDS and TB pandemics and the problem of the emerging burden of chronic non-communicable diseases will be significant competitors for these limited resources as parasitic infections aside from malaria tend to be chronic disabling problems of the poorest who have limited access to scarce health services and are representative of the poorest quintile. Prioritization and advocacy for parasite control in the national and international political environments is the challenge.

Development and implementation of a culturally sensitive cervical health survey: a community-based participatory approach.

Cervical cancer mortality rates are higher for Great Plains Native American women than for Caucasian women and other Native women. Messengers for Health, a project based on the Apsáalooke (Crow Indian) reservation, utilizes a lay health advisor approach to decrease cervical cancer screening barriers, increase knowledge regarding screening and prevention, and increase the proportion of women receiving Pap tests among Apsáalooke women aged 18 and older. This project utilizes a community-based participatory research model, which emphasizes community member involvement in all phases of the project. The initial phase of this project was the development and implementation of a culturally sensitive survey used to guide the program and benefit the community. The process and preliminary results are presented.

European health systems and cancer care.

INTRODUCTION: Data on the survival of all incident cases collected by population-based cancer registries make it possible to evaluate the overall performance of diagnostic and therapeutic actions on cancer in those populations. EUROCARE-3 is the third round of the EUROCARE project, the largest cancer registry population based collaborative study on survival in European cancer patients. The EUROCARE-3 study analysed the survival of cancer patients diagnosed from 1990 to 1994 and followed-up to 1999. Sixty-seven cancer registries of 22 European countries characterised by differing health systems participated in the study. This paper includes essays providing brief overviews of the state and evolution of the health systems of the considered countries and comments on the relation between cancer survival in Europe and some European macro-economic and health system indicators, in the 1990s. OVERVIEW OF THE EUROPEAN HEALTH SYSTEMS: The European health systems underwent a great deal of reorganisation in the last decade; a general tendency being to facilitate expanding involvement of the private sector in health care, a process which occurred mainly in the eastern countries (i.e. the Czech Republic, Estonia, Poland, Slovakia and Slovenia). In contrast, organisational changes in the northern European countries (i.e. Denmark, Iceland, Finland and Sweden) tended to confirm the established public sector systems. Other countries, including the UK and some southern European countries (i.e. England, Scotland, Wales, Malta and Italy) have reduced the public role while the systems remain basically public, at least at present. Our findings clearly suggest that cancer survival (all cancer combined) is related to macro-economic variables such as the gross domestic product (GDP), the total national (public and private) expenditure on health (TNEH) and the total public expenditure on health (TPEH). We found, however, that survival is related to wealth (GDP), but only up to a certain level, after which survival continues to be related to the level of health investment (both TNEH and TPEH). According to the Organisation for Economic Co-operation and Development (OECD), the TNEH increased during the 1990s in all EUROCARE-3 countries, while the ratio of TPEH to TNEH reduced in all countries except Portugal. CONCLUSIONS: Cancer survival depends on the widespread application of effective diagnosis and treatment modalities, but our enquiry suggests that the availability of these depends on macro-economic determinants, including health and public health investment. Analysis of the relationship between health system organisation and cancer outcome is complicated and requires more information than is at present available. To describe cancer and cancer management in Europe, the European Cancer Health Indicator Project (EUROCHIP) has proposed a list of indicators that have to be adopted to evaluate the effects on outcome of proposed health system modifications.