Assessing clinical significance of treatment outcomes using the DASS-21.

Standard clinical significance classifications are based on movement between the "dysfunctional" and "functional" distributions; however, this dichotomy ignores heterogeneity within the "dysfunctional" population. Based on the methodology described by Tingey, Lambert, Burlingame, and Hansen (1996), the present study sought to present a 3-distribution clinical significance model for the 21-item version of the Depression Anxiety Stress Scales (DASS-21; P. F. Lovibond & Lovibond, 1995) using data from a normative sample (n = 2,914), an outpatient sample (n = 1,000), and an inpatient sample (n = 3,964). DASS-21 scores were collected at pre- and post-treatment for both clinical samples, and patients were classified into 1 of 5 categories based on whether they had made a reliable change and whether they had moved into a different functional range. Evidence supported the validity of the 3-distribution model for the DASS-21, since inpatients who were classified as making a clinically significant change showed lower symptom severity, higher perceived quality of life, and higher clinician-rated functioning than those who did not make a clinically significant change. Importantly, results suggest that the new category of recovering is an intermediate point between recovered and making no clinically significant change. Inpatients and outpatients have different treatment goals and therefore use of the concept of clinical significance needs to acknowledge differences in what constitutes a meaningful change.

Integration of leprosy into GHS in India: a follow up study (2006-2007).

In India leprosy services, were integrated into the General Health Services (GHS), in a phased manner, in different provinces, from 2001 to 2004. This study reports the findings from a follow-up operational research undertaken in 2006-2007, to assess the level of integration, on predetermined indicators related to: referral services, training of health functionaries, availability of diagnosis, treatment, MDT dispersal and counselling guidelines in health facilities, recording and reporting by GHS staff, MDT stock management and involvement of health sub-centres in different Indian provinces. Nine provinces, 18 districts, 88 health facilities and 108 sub-centres were selected, by using multistage stratified random sampling techniques. Reverse integration, as reflected by the training and deployment of vertical staff in GHS, was also assessed. Data was collected by medical officers experienced in leprosy, with the assistance of state health functionaries, and recorded on separate schedules for health facility and sub-centre levels. The study also touched on the issue of client perception towards MDT services by interviewing 149 under treatment/cured leprosy cases (who had completed treatment within the last year), in the community with the help of local interpreters. Results showed wide variations across the selected provinces in various parameters. District leprosy nuclei were understaffed in 12(66.7%) districts, and district hospitals were not working as referral institutions anywhere. The training status of medical officers and multi-purpose workers in leprosy was low in Andhra Pradesh (6.9 and 22.4%), Madhya Pradesh (26.3 and 14.5%), Rajasthan (19.7 and 40.9%) and Kerala (25.5 and 65.7%). MDT stock availability as per the National Leprosy Eradication Programme (NLEP) guidelines was not adequate in all provinces. Availability of patient counseling guidelines was nil/low in Kerala, Karnataka, West Bengal, Orissa, Rajasthan and Andhra Pradesh. The involvement of sub-centres, in case referral, recording and dispensing MDT was nil Kerala and Rajasthan and poor in Andhra Pradesh. Ninety percent of clients in Kerala and 38.0% in Andhra Pradesh and Madhya Pradesh did not get MDT in the nearest health facilities or sub-centres.

Evaluation of psychodynamic psychotherapy in a community mental health center.

This study describes an evaluation of the effectiveness of psychodynamic psychotherapy provided in an outpatient community mental health clinic. The study used a single group pretest-posttest design involving 78 clients. Clinical outcomes included overall psychosocial functioning and quality of life, level of subjective distress, interpersonal functioning and role functioning, measured by the Outcome Questionnaire (Lambert, Hansen, Umpress, Lunnen Okilshi, & Burlingame, 2000). Clients showed statistically significant improvement from pretest (first sessions) to completion of treatment in overall functioning, and quality of life, level of subjective distress, interpersonal functioning and role functioning. Eighty-five percent of clients made statistically and clinically significant change. Calculation of effect sizes for each outcome found moderate to strong change effects ranging from d = .4 to .9. The study illustrates a method of intervention research that therapists and agencies can use to integrate practical evaluation methods into their clinical services in order to improve mental health service to clients, to demonstrate the effectiveness of interventions, and to provide data to support coverage for needed services for clients.

Gains and losses of structured information collection in the evaluation of 'rehabilitation in the community' programmes: ten lessons learnt during actual evaluations.

PURPOSE: Previously we have explored definitions of community-based rehabilitation (CBR) and proposed a way of classifying rehabilitation programmes by describing their essential characteristics. As the next step, we proposed two flow charts that guide the evaluator through a characterization of the programme and then indicate the information that should be collected. The present paper describes the application of this methodology in five actual evaluations of programmes aiming at socio-economic rehabilitation of persons affected by leprosy. METHOD: We compared the information as required by the flow charts to the information presented in the evaluation reports and asked: "Does this methodology adequately describe and reveal all relevant aspects of the rehabilitation programme?" RESULTS: Use of the flow charts led to discussion between evaluators and programme staff about how each would characterize the programme; this was a valuable step in the evaluation process and provided insight to the staff into their current practices and aspirations. The rehabilitation services as such were always well-described in the evaluation reports. More attention could have been given to the programme environment and provider-client relationships. More or more explicit attention than required by the flow charts could be given to linkages with other rehabilitation programmes and community organizations; questions of organizational capacity; systems to maintain and increase the quality of services; and conditions and constraints imposed by donor organizations. In order to show their effectiveness, rehabilitation programmes need to develop simple information systems which show progress of clients towards the rehabilitation goals defined for them, with them or by them. Impact can be demonstrated by an assessment one year after ending the intervention. This should include assessments of clients' psychological and social status. CONCLUSIONS: The original theoretical framework has proven its value in evaluation practice. The flow charts accommodate a variety of programmes and address the specific aims, contexts and developmental stages of the programmes evaluated. Taking the lessons learnt here into account will further improve the usefulness and practical relevance of the methodology we proposed.

Avaliação do programa de eliminação da hanseníase em Mato Grosso (2001 - 2003) / Evaluation of the program of elimination of leprosy at the state of Mato Grosso - Brazil (2001-2003)

Objetivo: avaliar a implantação do “Projeto Prioritário Tolerância Zero: Mato Grosso sem hanseníase”(projeto TZ) da Secretaria de Estado de Saúde de Mato Grosso (SES/MT) no período de 2001 a 2003. Método: pesquisa avaliativa da implantação do projeto TZ que considera a análise dos contextos organizacional e externo interferindo no grau de implantação e na efetividade da intervenção. Resultados: em relação ao contexto organizacional, Peixoto de Azevedo foi considerado“adequado” com escore de 95,5%, e os demais “aceitáveis”. Esta dimensão traduz a apropriação do programa pelas secretarias municipais de saúde e as condições técnicas-gerenciais e políticas da sua execução. Segundo as condições sócio-sanitárias avaliadas, no contexto externo Cuiabá foi considerada como “aceitável” e os demais municípios “insuficientes”. Peixoto de Azevedo e Poconé apresentaram escores “aceitáveis”, quanto ao grau de implantação do Projeto Tolerância Zero, destacando a cobertura do Programa Saúde da Família, principalmente na atenção integral e investigação dos contatos. Apenas Poconé apresentou índices “aceitáveis” na avaliação da efetividade da intervenção. Nos demais municípios, esta dimensão foi avaliada como “insuficiente”. A importância da intervenção deveu-se à mobilização política e estratégias adotadas pela SES/MT. Conclusão: os maiores escores no grau de implantação foram verificados nos municípios voltados ao fortalecimento do Programa de Saúde da Família e descentralização do atendimento. A efetividade, que inclui dados epidemiológicos, foi influenciada pelo modelo assistencial e pela magnitude da doença nos anos anteriores.

Objective: to evaluate the implementation of the " Null Tolerance Priority Project: State of MatoGrosso Without Leprosy" (the TZ project) of the State Secretariat of Health, during 2001 to 2003.Method: evaluative research of the implementation of the TZ project, considering the analysis of theexternal and organizational contexts affecting the extent of the implementation and the effectivenessof the intervention. Results: as for the organizational context, Peixoto de Azevedo was considered"adequate" with score 95.5%, and the other municipalities, just "acceptable". This accounts for the appropriation of programs by the Municipal Secretariats of Health and their technical-managerial and political conditions for the execution. As for the social and sanitary conditions evaluated in the externalcontext, Cuiabá was considered "acceptable" and the others, "insufficient". Peixoto de Azevedo and Poconé presented "acceptable" scores as regards the extent of the TZ Project’s implementation, withhighlighted importance given to the role the Health Family Program played especially in the integralassistance and contacts surveillance. Only Poconé presented "acceptable" rates of effectiveness. Theother municipalities were evaluated as "insufficient” in this dimension. The importance of the intervention results from the political mobilization and strategies adopted by the State of Mato Grosso Secretariat of Health. Conclusion: highest scores of implementation were verified in thosemunicipalities with policies toward the strengthening of the Health Family Program and decentralization of the health providers. The effectiveness, which included epidemiological databases, was influenced by the health assistance model and by the magnitude of the illness in the previousyears.

Leprosy control activities in India: integration into general health system.

Integration of leprosy control into the general health system is an essential element of a leprosy elimination strategy. In India, the process has been undertaken with the assistance of World Bank in a phased manner. In the first phase (2001-2002), 24 low/moderately endemic provinces for leprosy were targeted. Operational research was undertaken in these low/moderate endemic provinces to assess the progress of integration of leprosy control in general health system using defined categories, viz. structural integration, training status, availability of MDT and recording/reporting of cases. Selection of nine provinces, 18 districts, 86 health facilities and 108 sub-centres was performed using multistage stratified random sampling technique. Data were collected by interviewing GHS/vertical staff, scrutiny of records and spot checking of MDT stock by Health officers of three leprosy institutions of the Government of India. The result showed that district leprosy nuclei had formed in 16 of 18 districts. In 56% of health facilities vertical staff were redeployed for delivering general health care. Forty-five percent of medical officers, 71% of health supervisors and 75% of multipurpose workers were trained in leprosy. MDT treatment was available in >80% of health facilities. In only 2% of health facilities 3 months MDT stock of all types was present. Forty-four percent of sub-centres were delivering subsequent doses (second dose onward) of MDT. Reporting through a simplified information system was universal. This study emphasizes the need for reorientation training of Medical Officers, better MDT stock management and decentralized management of cases up to sub-centre level.

Proyecto de prevención de discapacidades y rehabilitación física para enfermos de lepra. Provincia de Jiangxi, china / No disponible

La Asociación Fontilles, miembro de la Federación Internacional de Asociaciones de Lucha contra la Lepra (ILEP), inicia su trabajo en China colaborando con otros miembros de dicha Federación, y con el Centro Nacional para el Control de Enfermedades de Transmisión Sexual y Lepra de Nanjing en el tercer estadio del Proyecto nacional de Prevención de Discapacidades (PDD) y Rehabilitación Física en la República Popular China. La Asociación Fontilles ha trabajado en esta provincia durante cinco años del 2000 al 2004. El artículo pretende describir las actividades básicas relacionadas con el Proyecto y los resultados obtenidos tras llevarlas a cabo (AU)

No disponible

Progress towards the elimination of leprosy in Nigeria: a review of the role of policy implementation and operational factors.

The annual reports of the national leprosy control programme in Nigeria were reviewed to study the trends of the indices of leprosy control from 1992 to 2003 and determine the influence of operational and policy factors. By 2003, both national prevalence and case detection rates had reached below 0.5 per 10,000. Sub-nationally, all except three contiguous States in the Southeast, had prevalence rates below one case per 10,000. Over the 12 years, the prevalence rate decreased by 94-1%, from 7.14 to 0.42 per 10,000, with two periods of rapid decline: 1992-1994 and 1998. Remarkable surges of discharges from multi-drug therapy (MDT) occurred in these same periods. The period 1992-1994 corresponds to the years of introduction of MDT, case reviews, and clean-up of leprosy registers nationwide, while 1998 corresponds to the year the programme adopted the shortened 12-month MDT regime for multibacillary (MB) leprosy. The overall trend of case detection since 1992 was relatively stable, but had three significant periods of initial increase (1992-1994), stability (1994-1999) and recent decline (1999-2003), apparently related to the changing levels of activeness of the national programme. The pattern of new cases detected revealed increasing MB classification and lower disability, but a relatively stable child rate since 1992. The trend of MB proportion was also related to the years of MDT introduction and the adoption of a new leprosy case definition and classification policies. Thus, Nigeria has attained a low leprosy endemic status-mainly through operational and policy influences. The challenges that remain include reducing the relatively high leprosy burden in the Southeastern States and evolving effective case detection interventions that will make an observable impact on the incidence of leprosy.

Estudo de caso da avaliação da descentralização das ações programáticas de hanseníase / Study of case of the evaluation of the decentralization of the programmatical actions of hanseníase

A hanseníase, doença endêmica nacional, ainda que nos últimos anos apresente uma redução importante no número de casos, se constitui um problema de saúde pública. Para reverter este quadro, estratégias vem sendo adotadas para sua eliminação como problema de saúde pública até o ano 2005. Dentre essas estratégias destaca-se a descentralização das ações programáticas de hanseníase para toda a rede básica de saúde do país.No que diz respeito ao Programa de Controle da Hanseníase, embora o Ministério da Saúde realize avaliações anuais do programa aplicando seu instrumento de avaliação composto por um conjunto de indicadores epidemiológicos e operacionais, este não subsidia a análise do processo e dos resultados das intervenções empregadas nacionalmente para uma redução da endemia. Assim definiu-se pelo desenvolvimento de uma pesquisa avaliativa para analisar a influência da autonomia em suas quatro dimensões, política, financeira, administrativo/gerencial e técnica sobre a intervenção que vem sendo assumida pelos municípios brasileiros, a universalização do acesso da população ao diagnóstico e tratamento da hanseníase na rede básica de saúde. Apoiando-se em uma revisão teórico-metodológica da avaliação em saúde, construiu-se um modelo de avaliação utilizando-se como método o Modelo Lógico, que tem como essência a utilização de matrizes segundo o objeto de estudo. Foram criadas uma Matriz Descritiva, uma Matriz de Análise e uma Matriz de Julgamento.Este Modelo Lógico de Avaliação foi aplicado no município de Nova Iguaçu, estado do Rio de Janeiro, para avaliar os progressos e os resultados obtidos com a descentralização das ações programáticas de hanseníase em sua rede de saúde.Os resultados deste estudo mostraram que o grau de autonomia alcançado pelo município de Nova Iguaçu é baixo. Os indicadores definidos para medir o grau de autonomia política, financeira, administrativo e técnico demonstraram que o município se encontrava na esfera de compromissos, com poucos compromissos transformados em ações.Em se tratando de uma doença prevalente, a hanseníase requer cada vez mais o desenvolvimento de pesquisas avaliativas que subsidiem os responsáveis pela tomada de decisões, na implementação de políticas que eliminem a doença como problema de saúde pública.

Considerações acerca dos estados reacionais do portador de Hanseníase no Município de Itajaí / Considerations on reactional states of Itajaí's hansen's carriers

A pesquisa teve por objetivo, compreender e avaliar os estados reacionais de pacientes portadores de hanseníase e o tratamento das reações. O método de abordagem do estudo foi indutivo, tendo como base o referencial bibliográfico, tomou-se como fonte de dados os prontuários dos portadores de hanseníase, disponíveis no Programa de Controle de Hanseníase da Secretaria Municipal de Saúde de Itajaí. Através do trabalho com os 78 pacientes inscritos no programa, observou-se que: 60,3 por cento tem de 15-49 anos; 65,4 por cento são do sexo masculino; 70,5 por cento manifestam a forma Virchowiana da doença; 60,3 por cento apresentaram estados reacionais durante tratamento; metade destes aproximadamente apresentaram quadro clínico de neurite, tendo sido tratados com prednisona. Também foram observados outros sintomas clínicos como o eritema nodoso hansênico, e o tratamento de escolha, sempre que possível foi a talidomida. A avaliação dos estados reacionais indica que, mais da metade dos portadores em tratamento, apresentam esta manifestação imunológica. É julgada pela literatura como consequência da doença e possível reação ao esquema poliquimioterápico

Atuaçäo do PACS e PSF em Teresina: alguns resultados / Some results of programs community agents and family health programs of Teresina, Brazil

O objetivo do programa é melhorar o estado de saúde da população, mediante ações integradas dirigidas ao indivíduos, à família, à comunidade e ao meio ambiente, voltadas para a promoção e a proteção da saúde, além da identificação e tratamento precoce das doenças. Ressalta como atividade do Programa de Agentes Comunitários de Saúde o acompanhamento a grupos específicos (gestantes, crianças, idosos, portadores de doenças crônico-degenerativas (diabetes e hipertensão) e doenças transmissíveis (tuberculose e hanseníase). Segundo dados do Sistema de Informações das Ações Básicas, foi registrada a média de 1,02 visitas/mês por família, para o período de maio a dezembro de 1998, cumprindo, a meta estabelecida pelas diretrizes do programa

The world health report 1998: life in the 21st century A vision for all

What will life in the 21st century? Will the world continue to grow healthier, with ever more diseases conquered by scientific advances, and life expectancy extending even longer? Or will new diseases and failing drugs cancel out these gains? If populations live longer, will these extra years be healthy and productive or merely an extended sentence of suffering? Will continuing population growth finally stifle the panet's life, depleting finite resources, polluting beyond repair, and making megacities and urban slums the home for more and more? Or will better finally planning options - and mounting deaths from AIDS - reverse recent trends? Will we conquer malnutrition, obesity, drug abuse, poverty, depression, and the common cold? Will we eradicate polio, leprosy, measles and other anciest foes? Will deaths from heart disease and cancer finally begin to decline? And when will be able to afford them? Will the gaps between the health of rich and poor grow ever wider? These are some of the many questions addressed in The World Health Report 1998. Issued as the World Health Organization marks its 50th anniversary, the report takes an expert look at health trends over the past five decades, assesses the current global situation, and predicts how health conditions, diseases, and the tools for managing them will evolve up to the year 2025. Using the latest data gathered and validated by WHO, the report paints a picture of a world posed to achieve unprecedent good health - if the lessons learned during recent decades are understood and heeded

The world health report 1998: life in the 21st century A vision for all / The world health report 1998: life in the 21st century A vision for all

What will life in the 21st century? Will the world continue to grow healthier, with ever more diseases conquered by scientific advances, and life expectancy extending even longer? Or will new diseases and failing drugs cancel out these gains? If populations live longer, will these extra years be healthy and productive or merely an extended sentence of suffering? Will continuing population growth finally stifle the panet's life, depleting finite resources, polluting beyond repair, and making megacities and urban slums the home for more and more? Or will better finally planning options - and mounting deaths from AIDS - reverse recent trends? Will we conquer malnutrition, obesity, drug abuse, poverty, depression, and the common cold? Will we eradicate polio, leprosy, measles and other anciest foes? Will deaths from heart disease and cancer finally begin to decline? And when will be able to afford them? Will the gaps between the health of rich and poor grow ever wider? These are some of the many questions addressed in The World Health Report 1998. Issued as the World Health Organization marks its 50th anniversary, the report takes an expert look at health trends over the past five decades, assesses the current global situation, and predicts how health conditions, diseases, and the tools for managing them will evolve up to the year 2025. Using the latest data gathered and validated by WHO, the report paints a picture of a world posed to achieve unprecedent good health - if the lessons learned during recent decades are understood and heeded

Sistema de vigilancia en salud pública: una mirada atenta / Surveillance system in public health: an attentive look

Se abordan problemas de salud desde el punto de vista de la vigilancia epidemiológica, en función del impacto que éstos tengan sobre los niveles de salud-enfermedad en México. El documento contiene los siguientes capítulos: 1. Presentación 2. Prólogo 3. Introducción 4. Sistema de Vigilancia Epidemiológica Simplificada 5. Vigilancia epidemiológica de la tuberculosis 6. Vigilancia epidemiológica de la lepra 7. Sistema de Vigilancia Epidemiológica de Daños a la Salud por Efecto de los Contaminantes Ambientales 8. Sistema de Vigilancia Epidemiológica de las Adicciones 9. Escenarios de futuro inmediato 10. Bibliografía

A hanseníase e as práticas sanitárias em São Paulo: 10 anos de sub-programa de controle da hanseníase na Secretaria de Estado da Saúde (1977 - 1987) / Leprosy and sanitary practices in São Paulo, Brazil: 10 years of the sub-program of leprosy control in the Health State Department (1977 - 1987)

Trata da organização do trabalho nos Centros de Saúde da rede institucional da Secretaria de Estado da Saúde de São Paulo, considerando em especial as práticas referidas ao controle da hanseníase no período 1977 - 1987. Fundamentou-se o estudo no conceito de modelo de organização tecnológica do trabalho como quadro teórico de análise das formas de organização dos processos de trabalho nos serviços de saúde. Assim, tanto a recuperação histórica das práticas de controle da hanseníase como a análise de suas características no período 1977-1987 foi realizada buscando-se identificar a organização tecnológica concretamente operada