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1.
Trials ; 21(1): 52, 2020 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-31915039

RESUMO

BACKGROUND: Improving the health and development of adolescents aged 10-19 years is a global health priority. One in five adolescents globally live in India. The Rashtriya Kishor Swasthya Karyakram (RKSK), India's national adolescent health strategy, recommends supporting community-based peer educators to conduct group meetings with boys and girls. Groups aim to give adolescents a space to discuss the social and health issues affecting them and build their capacity to become active community members and leaders. There have been no evaluations of the community component of RKSK to date. In this protocol, we describe the evaluation of the Jharkhand Initiative for Adolescent Health (JIAH), a community intervention aligned with RKSK and designed to improve school attendance, dietary diversity and mental health among adolescent girls aged 10-19 years in rural Jharkhand, eastern India. METHODS: The JIAH intervention is delivered by a community youth team consisting of yuva saathis (friends of youth), youth leadership facilitators and livelihood promoters. Teams conduct (a) peer-led Participatory Learning and Action meetings with girls and boys, mobilising adolescents, parents, health workers, teachers and the wider community to make changes for adolescent health and development; (b) group-based youth leadership activities to build adolescents' confidence and resilience; and (c) livelihood promotion with adolescents and their families to provide training and practical skills. We are evaluating the JIAH intervention through a parallel-group, two-arm, superiority, cluster-randomised controlled trial. The unit of randomisation is a geographic cluster of ~1000 people. A total of 38 clusters covering an estimated population of 40,676 have been randomised to control or intervention arms. Nineteen intervention clusters have adolescent groups, youth leadership activities and livelihood promotion. Nineteen control clusters receive livelihood promotion only. Study participants are adolescent girls aged 10-19 years, married or unmarried, in or out of school, living in the study area. Intervention activities are open to all adolescent boys and girls, regardless of their participation in surveys. We will collect data through baseline and endline surveys. Primary trial outcomes are school attendance, dietary diversity and internalising and externalising mental health problems. Secondary outcomes include access to school-related entitlements, emotional or physical violence, self-efficacy and resilience. TRIAL REGISTRATION: ISRCTN17206016. Registered on 27 June 2018.

2.
PLoS Med ; 16(10): e1002934, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31613883

RESUMO

BACKGROUND: Recent data suggest that case fatality from severe acute malnutrition (SAM) in India may be lower than the 10%-20% estimated by the World Health Organization (WHO). A contemporary quantification of mortality and recovery from acute malnutrition in Indian community settings is essential to inform policy regarding the benefits of scaling up prevention and treatment programmes. METHODS AND FINDINGS: We conducted a cohort study using data collected during a recently completed cluster-randomised controlled trial in 120 geographical clusters with a total population of 121,531 in rural Jharkhand and Odisha, eastern India. Children born between October 1, 2013, and February 10, 2015, and alive at 6 months of age were followed up at 9, 12, and 18 months. We measured the children's anthropometry and asked caregivers whether children had been referred to services for malnutrition in the past 3 months. We determined the incidence and prevalence of moderate acute malnutrition (MAM) and SAM, as well as mortality and recovery at each follow-up. We then used Cox-proportional models to estimate mortality hazard ratios (HRs) for MAM and SAM. In total, 2,869 children were eligible for follow-up at 6 months of age. We knew the vital status of 93% of children (2,669/2,869) at 18 months. There were 2,704 children-years of follow-up time. The incidence of MAM by weight-for-length z score (WLZ) and/or mid-upper arm circumference (MUAC) was 406 (1,098/2,704) per 1,000 children-years. The incidence of SAM by WLZ, MUAC, or oedema was 190 (513/2,704) per 1,000 children-years. There were 36 deaths: 12 among children with MAM and six among children with SAM. Case fatality rates were 1.1% (12/1,098) for MAM and 1.2% (6/513) for SAM. In total, 99% of all children with SAM at 6 months of age (227/230) were alive 3 months later, 40% (92/230) were still SAM, and 18% (41/230) had recovered (WLZ ≥ -2 standard deviation [SD]; MUAC ≥ 12.5; no oedema). The adjusted HRs using all anthropometric indicators were 1.43 (95% CI 0.53-3.87, p = 0.480) for MAM and 2.56 (95% CI 0.99-6.70, p = 0.052) for SAM. Both WLZ < -3 and MUAC ≥ 11.5 and < 12.5 were associated with increased mortality risk (HR: 3.33, 95% CI 1.23-8.99, p = 0.018 and HR: 3.87, 95% CI 1.63-9.18, p = 0.002, respectively). A key limitation of our analysis was missing WLZ or MUAC data at all time points for 2.5% of children, including for two of the 36 children who died. CONCLUSIONS: In rural eastern India, the incidence of acute malnutrition among children older than 6 months was high, but case fatality following SAM was 1.2%, much lower than the 10%-20% estimated by WHO. Case fatality rates below 6% have now been recorded in three other Indian studies. Community treatment using ready-to-use therapeutic food may not avert a substantial number of SAM-related deaths in children aged over 6 months, as mortality in this group is lower than expected. Our findings strengthen the case for prioritising prevention through known health, nutrition, and multisectoral interventions in the first 1,000 days of life, while ensuring access to treatment when prevention fails.

3.
BMC Public Health ; 19(1): 673, 2019 May 31.
Artigo em Inglês | MEDLINE | ID: mdl-31151394

RESUMO

BACKGROUND: India is home to 243 million adolescents. Two million (9%) of them belong to Scheduled Tribes living in underserved, rural areas. Few studies have examined the health of tribal adolescents. We conducted a cross-sectional survey to assess the health, nutrition and wellbeing of adolescent girls in rural Jharkhand, eastern India, a state where 26% of the population is from Scheduled Tribes. We aimed to identify priorities for community interventions to serve adolescents and their families. METHODS: Between June 2016 and January 2017, interviewers visited all households in 50 purposively sampled villages of West Singhbhum district, Jharkhand. They aimed to interview all girls aged 10-19. Interviewers conducted face-to-face interviews with girls to administer a survey about physical and mental health, disability, nutrition, sexual and reproductive health, gender norms, decision-making, education and violence. Interviewers also measured girls' height, weight, and Mid-Upper Arm Circumference. RESULTS: Interviewers collected data from 3324 (82%) of an estimated 4068 girls residing in the study area. Their mean age was 14.3 (SD 2.9). 82% were from Scheduled Tribes. 89% of younger girls aged 10-14 and 46% of older girls aged 15-19 were in school or college. Girls dropped out of school because they were required for household work (37%) or work on the family farm or business (22%). Over a third reported symptoms of anaemia in the past month, but less than a fifth had a blood test. The prevalence of thinness (<-2SD median BMI for age and sex) was 14% for younger girls and 6% for older girls. 45% of girls were stunted (<-2SD median height for age and sex). 40% reported emotional violence in the past year, 14% physical violence, and 0.7% sexual violence. 12% had problems associated with depression or anxiety. 30% aged 15-19 had heard of contraception. Among married girls and their husbands, only 10% had ever used methods to prevent or delay pregnancy. CONCLUSIONS: Our study identified several priorities to improve adolescent girls' health, nutrition and wellbeing in largely tribal areas of Jharkhand: reducing violence, early marriage and undernutrition, as well as improving mental health, knowledge about contraception and school retention.


Assuntos
Saúde do Adolescente/estatística & dados numéricos , Saúde Mental/estatística & dados numéricos , Estado Nutricional , Saúde da População Rural/estatística & dados numéricos , Adolescente , Criança , Estudos Transversais , Feminino , Inquéritos Epidemiológicos , Humanos , Índia/epidemiologia , Pesquisa Qualitativa , Adulto Jovem
4.
Trials ; 19(1): 176, 2018 Mar 09.
Artigo em Inglês | MEDLINE | ID: mdl-29523173

RESUMO

BACKGROUND: Maternal and child undernutrition have adverse consequences for pregnancy outcomes and child morbidity and mortality, and they are associated with low educational attainment, economic productivity as an adult, and human wellbeing. 'Nutrition-sensitive' agriculture programs could tackle the underlying causes of undernutrition. METHODS/DESIGN: This study is a four-arm cluster randomised controlled trial in Odisha, India. Interventions are as follows: (1) an agricultural extension platform of women's groups viewing and discussing videos on nutrition-sensitive agriculture (NSA) practices, and follow-up visits to women at home to encourage the adoption of new practices shown in the videos; (2) women's groups viewing and discussing videos on NSA and nutrition-specific practices, with follow-up visits; and (3) women's groups viewing and discussing videos on NSA and nutrition-specific practices combined with a cycle of Participatory Learning and Action meetings, with follow-up visits. All arms, including the control, receive basic nutrition training from government community frontline workers. Primary outcomes, assessed at baseline and 32 months after the start of the interventions, are (1) percentage of children aged 6-23 months consuming ≥ 4 out of 7 food groups per day and (2) mean body mass index (BMI) (kg/m2) of non-pregnant, non-postpartum (gave birth > 42 days ago) mothers or female primary caregivers of children aged 0-23 months. Secondary outcomes are percentage of mothers consuming ≥ 5 out of 10 food groups per day and percentage of children's weight-for-height z-score < -2 standard deviations (SD). The unit of randomisation is a cluster, defined as one or more villages with a combined minimum population of 800 residents. There are 37 clusters per arm, and outcomes will be assessed in an average of 32 eligible households per cluster. For randomisation, clusters are stratified by distance to nearest town (< 10 km or ≥ 10 km), and low (< 30%), medium (30-70%), or high (> 70%) proportion of Scheduled Tribe or Scheduled Caste (disadvantaged) households. A process evaluation will assess the quality of implementation and mechanisms behind the intervention effects. A cost-consequence analysis will compare incremental costs and outcomes of the interventions. DISCUSSION: This trial will contribute evidence on the impacts of NSA extension through participatory, low-cost, video-based approaches on maternal and child nutrition and on whether integration with nutrition-specific goals and enhanced participatory approaches can increase these impacts. TRIAL REGISTRATION: ISRCTN , ISRCTN65922679 . Registered on 21 December 2016.


Assuntos
Agricultura/métodos , Produtos Agrícolas/provisão & distribução , Abastecimento de Alimentos , Transtornos da Nutrição do Lactente/prevenção & controle , Fenômenos Fisiológicos da Nutrição do Lactente , Desnutrição/prevenção & controle , Fenômenos Fisiológicos da Nutrição Materna , Estado Nutricional , Serviços de Saúde Rural , Gravação em Vídeo , Adolescente , Adulto , Índice de Massa Corporal , Produtos Agrícolas/crescimento & desenvolvimento , Feminino , Visita Domiciliar , Humanos , Índia , Lactente , Transtornos da Nutrição do Lactente/diagnóstico , Transtornos da Nutrição do Lactente/fisiopatologia , Recém-Nascido , Masculino , Desnutrição/diagnóstico , Desnutrição/fisiopatologia , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Valor Nutritivo , Grupo Associado , Tamanho da Porção , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Recomendações Nutricionais , Saúde da População Rural , Adulto Jovem
5.
Lancet Glob Health ; 5(10): e1004-e1016, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28911749

RESUMO

BACKGROUND: Around 30% of the world's stunted children live in India. The Government of India has proposed a new cadre of community-based workers to improve nutrition in 200 districts. We aimed to find out the effect of such a worker carrying out home visits and participatory group meetings on children's linear growth. METHODS: We did a cluster-randomised controlled trial in two adjoining districts of Jharkhand and Odisha, India. 120 clusters (around 1000 people each) were randomly allocated to intervention or control using a lottery. Randomisation took place in July, 2013, and was stratified by district and number of hamlets per cluster (0, 1-2, or ≥3), resulting in six strata. In each intervention cluster, a worker carried out one home visit in the third trimester of pregnancy, monthly visits to children younger than 2 years to support feeding, hygiene, care, and stimulation, as well as monthly women's group meetings to promote individual and community action for nutrition. Participants were pregnant women identified and recruited in the study clusters and their children. We excluded stillbirths and neonatal deaths, infants whose mothers died, those with congenital abnormalities, multiple births, and mother and infant pairs who migrated out of the study area permanently during the trial period. Data collectors visited each woman in pregnancy, within 72 h of her baby's birth, and at 3, 6, 9, 12, and 18 months after birth. The primary outcome was children's length-for-age Z score at 18 months of age. Analyses were by intention to treat. Due to the nature of the intervention, participants and the intervention team were not masked to allocation. Data collectors and the data manager were masked to allocation. The trial is registered as ISCRTN (51505201) and with the Clinical Trials Registry of India (number 2014/06/004664). RESULTS: Between Oct 1, 2013, and Dec 31, 2015, we recruited 5781 pregnant women. 3001 infants were born to pregnant women recruited between Oct 1, 2013, and Feb 10, 2015, and were therefore eligible for follow-up (1460 assigned to intervention; 1541 assigned to control). Three groups of children could not be included in the final analysis: 147 migrated out of the study area (67 in intervention clusters; 80 in control clusters), 77 died after the neonatal period and before 18 months (31 in intervention clusters; 46 in control clusters), and seven had implausible length-for-age Z scores (<-5 SD; one in intervention cluster; six in control clusters). We measured 1253 (92%) of 1362 eligible children at 18 months in intervention clusters, and 1308 (92%) of 1415 eligible children in control clusters. Mean length-for-age Z score at 18 months was -2·31 (SD 1·12) in intervention clusters and -2·40 (SD 1·10) in control clusters (adjusted difference 0·107, 95% CI -0·011 to 0·226, p=0·08). The intervention did not significantly affect exclusive breastfeeding, timely introduction of complementary foods, morbidity, appropriate home care or care-seeking during childhood illnesses. In intervention clusters, more pregnant women and children attained minimum dietary diversity (adjusted odds ratio [aOR] for women 1·39, 95% CI 1·03-1·90; for children 1·47, 1·07-2·02), more mothers washed their hands before feeding children (5·23, 2·61-10·5), fewer children were underweight at 18 months (0·81, 0·66-0·99), and fewer infants died (0·63, 0·39-1·00). INTERPRETATION: Introduction of a new worker in areas with a high burden of undernutrition in rural eastern India did not significantly increase children's length. However, certain secondary outcomes such as self-reported dietary diversity and handwashing, as well as infant survival were improved. The interventions tested in this trial can be further optimised for use at scale, but substantial improvements in growth will require investment in nutrition-sensitive interventions, including clean water, sanitation, family planning, girls' education, and social safety nets. FUNDING: UK Medical Research Council, Wellcome Trust, UK Department for International Development (DFID).


Assuntos
Desenvolvimento Infantil , Aconselhamento , Visita Domiciliar , População Rural , Análise por Conglomerados , Feminino , Seguimentos , Humanos , Índia , Lactente , Fenômenos Fisiológicos da Nutrição do Lactente , Recém-Nascido , Masculino , Gravidez
6.
BMJ Open ; 6(11): e012046, 2016 11 02.
Artigo em Inglês | MEDLINE | ID: mdl-27807084

RESUMO

INTRODUCTION: Undernutrition affects ∼165 million children globally and contributes up to 45% of all child deaths. India has the highest proportion of global undernutrition-related morbidity and mortality. This protocol describes the planned economic evaluation of a community-based intervention to improve growth in children under 2 years of age in two rural districts of eastern India. The intervention is being evaluated through a cluster-randomised controlled trial (cRCT, the CARING trial). METHODS AND ANALYSIS: A cost-effectiveness and cost-utility analysis nested within a cRCT will be conducted from a societal perspective, measuring programme, provider, household and societal costs. Programme costs will be collected prospectively from project accounts using a standardised tool. These will be supplemented with time sheets and key informant interviews to inform the allocation of joint costs. Direct and indirect costs incurred by providers will be collected using key informant interviews and time use surveys. Direct and indirect household costs will be collected prospectively, using time use and consumption surveys. Incremental cost-effectiveness ratios (ICERs) will be calculated for the primary outcome measure, that is, cases of stunting prevented, and other outcomes such as cases of wasting prevented, cases of infant mortality averted, life years saved and disability-adjusted life years (DALYs) averted. Sensitivity analyses will be conducted to assess the robustness of results. ETHICS AND DISSEMINATION: There is a shortage of robust evidence regarding the cost-effectiveness of strategies to improve early child growth. As this economic evaluation is nested within a large scale, cRCT, it will contribute to understanding the fiscal space for investment in early child growth, and the relative (in)efficiency of prioritising resources to this intervention over others to prevent stunting in this and other comparable contexts. The protocol has all necessary ethical approvals and the findings will be disseminated within academia and the wider policy sphere. TRIAL REGISTRATION NUMBER: ISRCTN51505201; pre-results.


Assuntos
Desenvolvimento Infantil , Transtornos do Crescimento/prevenção & controle , Promoção da Saúde/métodos , Mortalidade Infantil , Saúde Pública/economia , Análise Custo-Benefício , Feminino , Assistência Alimentar , Promoção da Saúde/economia , Humanos , Índia , Lactente , Masculino , Avaliação de Programas e Projetos de Saúde , Projetos de Pesquisa , População Rural , Inquéritos e Questionários
7.
BMC Public Health ; 16: 59, 2016 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-26795942

RESUMO

BACKGROUND: In India, Village Health Sanitation and Nutrition Committees (VHSNCs) are participatory community health forums, but there is little information about their composition, functioning and effectiveness. Our study examined VHSNCs as enablers of participatory action for community health in two rural districts in two states of eastern India - West Singhbhum in Jharkhand and Kendujhar, in Odisha. METHODS: We conducted a cross-sectional survey of 169 VHSNCs and ten qualitative focus group discussions with purposively selected better and poorer performing committees, across the two states. We analysed the quantitative data using descriptive statistics and the qualitative data using a Framework approach. RESULTS: We found that VHSNCs comprised equitable representation from vulnerable groups when they were formed. More than 75 % members were women. Almost all members belonged to socially disadvantaged classes. Less than 1 % members had received any training. Supervision of committees by district or block officials was rare. Their work focused largely on strengthening village sanitation, conducting health awareness activities, and supporting medical treatment for ill or malnourished children and pregnant mothers. In reality, 62 % committees monitored community health workers, 6.5 % checked sub-centres and 2.4 % monitored drug availability with community health workers. Virtually none monitored data on malnutrition. Community health and nutrition workers acted as conveners and record keepers. Links with the community involved awareness generation and community monitoring of VHSNC activities. Key challenges included irregular meetings, members' limited understanding of their roles and responsibilities, restrictions on planning and fund utilisation, and weak linkages with the broader health system. CONCLUSIONS: Our study suggests that VHSNCs perform few of their specified functions for decentralized planning and action. If VHSNCs are to be instrumental in improving community health, sanitation and nutrition, they need education, mobilisation and monitoring for formal links with the wider health system.


Assuntos
Comitês Consultivos/organização & administração , Planejamento em Saúde/organização & administração , Desnutrição/epidemiologia , População Rural , Saneamento/métodos , Agentes Comunitários de Saúde/organização & administração , Participação da Comunidade , Estudos Transversais , Feminino , Grupos Focais , Promoção da Saúde/organização & administração , Humanos , Índia , Gravidez , Saúde Pública , Fatores Socioeconômicos
8.
Lancet Glob Health ; 4(2): e119-28, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26823213

RESUMO

BACKGROUND: A quarter of the world's neonatal deaths and 15% of maternal deaths happen in India. Few community-based strategies to improve maternal and newborn health have been tested through the country's government-approved Accredited Social Health Activists (ASHAs). We aimed to test the effect of participatory women's groups facilitated by ASHAs on birth outcomes, including neonatal mortality. METHODS: In this cluster-randomised controlled trial of a community intervention to improve maternal and newborn health, we randomly assigned (1:1) geographical clusters in rural Jharkhand and Odisha, eastern India to intervention (participatory women's groups) or control (no women's groups). Study participants were women of reproductive age (15-49 years) who gave birth between Sept 1, 2009, and Dec 31, 2012. In the intervention group, ASHAs supported women's groups through a participatory learning and action meeting cycle. Groups discussed and prioritised maternal and newborn health problems, identified strategies to address them, implemented the strategies, and assessed their progress. We identified births, stillbirths, and neonatal deaths, and interviewed mothers 6 weeks after delivery. The primary outcome was neonatal mortality over a 2 year follow up. Analyses were by intention to treat. This trial is registered with ISRCTN, number ISRCTN31567106. FINDINGS: Between September, 2009, and December, 2012, we randomly assigned 30 clusters (estimated population 156 519) to intervention (15 clusters, estimated population n=82 702) or control (15 clusters, n=73 817). During the follow-up period (Jan 1, 2011, to Dec 31, 2012), we identified 3700 births in the intervention group and 3519 in the control group. One intervention cluster was lost to follow up. The neonatal mortality rate during this period was 30 per 1000 livebirths in the intervention group and 44 per 1000 livebirths in the control group (odds ratio [OR] 0.69, 95% CI 0·53-0·89). INTERPRETATION: ASHAs can successfully reduce neonatal mortality through participatory meetings with women's groups. This is a scalable community-based approach to improving neonatal survival in rural, underserved areas of India. FUNDING: Big Lottery Fund (UK).


Assuntos
Pessoal de Saúde , Promoção da Saúde/métodos , Saúde do Lactente , Saúde Materna , Serviços de Saúde Materno-Infantil , Resultado da Gravidez , População Rural , Acreditação , Adulto , Países em Desenvolvimento , Feminino , Humanos , Índia/epidemiologia , Lactente , Mortalidade Infantil , Razão de Chances , Morte Perinatal , Gravidez , Natimorto , Adulto Jovem
9.
BMC Public Health ; 15: 384, 2015 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-25886587

RESUMO

BACKGROUND: Child stunting (low height-for-age) is a marker of chronic undernutrition and predicts children's subsequent physical and cognitive development. Around one third of the world's stunted children live in India. Our study aims to assess the impact, cost-effectiveness, and scalability of a community intervention with a government-proposed community-based worker to improve growth in children under two in rural India. METHODS: The study is a cluster randomised controlled trial in two rural districts of Jharkhand and Odisha (eastern India). The intervention tested involves a community-based worker carrying out two activities: (a) one home visit to all pregnant women in the third trimester, followed by subsequent monthly home visits to all infants aged 0-24 months to support appropriate feeding, infection control, and care-giving; (b) a monthly women's group meeting using participatory learning and action to catalyse individual and community action for maternal and child health and nutrition. Both intervention and control clusters also receive an intervention to strengthen Village Health Sanitation and Nutrition Committees. The unit of randomisation is a purposively selected cluster of approximately 1000 population. A total of 120 geographical clusters covering an estimated population of 121,531 were randomised to two trial arms: 60 clusters in the intervention arm receive home visits, group meetings, and support to Village Health Sanitation and Nutrition Committees; 60 clusters in the control arm receive support to Committees only. The study participants are pregnant women identified in the third trimester of pregnancy and their children (n = 2520). Mothers and their children are followed up at seven time points: during pregnancy, within 72 hours of delivery, and at 3, 6, 9, 12 and 18 months after birth. The trial's primary outcome is children's mean length-for-age Z scores at 18 months. Secondary outcomes include wasting and underweight at all time points, birth weight, growth velocity, feeding, infection control, and care-giving practices. Additional qualitative and quantitative data are collected for process and economic evaluations. DISCUSSION: This trial will contribute to evidence on effective strategies to improve children's growth in India. TRIAL REGISTRATION: ISRCTN register 51505201 ; Clinical Trials Registry of India number 2014/06/004664.


Assuntos
Transtornos da Nutrição Infantil/prevenção & controle , Agentes Comunitários de Saúde/organização & administração , Visita Domiciliar , Centros de Saúde Materno-Infantil/organização & administração , Educação de Pacientes como Assunto/organização & administração , Adulto , Desenvolvimento Infantil , Pré-Escolar , Agentes Comunitários de Saúde/economia , Análise Custo-Benefício , Aconselhamento , Feminino , Humanos , Índia/epidemiologia , Lactente , Recém-Nascido , Centros de Saúde Materno-Infantil/economia , Mães , Estado Nutricional , Educação de Pacientes como Assunto/economia , Cuidado Pós-Natal , Gravidez , Terceiro Trimestre da Gravidez , População Rural
10.
Nicotine Tob Res ; 17(7): 784-95, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25589676

RESUMO

INTRODUCTION: Graphic warning labels have been shown to be more effective than text-only labels in increasing attention and perceived health risks, but most U.S. studies have involved single exposures in laboratory or Internet settings. METHODS: We recruited a convenience sample (N = 202) of U.S. adult smokers from population subgroups with higher rates of smoking and smoking-related deaths who had participated in a larger survey about graphic warning labels. Participants were randomized to get 1 of 9 graphic + text labels or a text-only label. Research staff affixed a warning label sticker to participants' cigarette pack(s) at enrollment. Color graphic labels covered slightly more than the lower half of packs. Black and white labels of current U.S. text-only warnings covered the existing side warning to prompt attention to the label (i.e., attention control). Participants received extra stickers of the same label for subsequent packs, and completed 3 telephone interviews in 1 week. RESULTS: Participants reported low avoidance (<34%) and consistent use of the stickers (91%). Smokers consistently paid more attention to graphic than text-only labels. Only 5 of the 9 graphic warning labels were significantly associated with greater thoughts of health risks. Thinking about quitting and stopping smoking did not differ by label. Qualitative data illustrated differences in the "stickiness," self-referencing, and counterarguments of graphic warning labels. CONCLUSIONS: U.S. smokers' reactions to graphic warning labels on their own packs were similar to other, more controlled studies. Qualitative findings underscore the need for warning labels that encourage self-referential processing without increasing defensive reactions.


Assuntos
Rotulagem de Produtos/métodos , Fumar/epidemiologia , Fumar/psicologia , Inquéritos e Questionários , Produtos do Tabaco/efeitos adversos , United States Food and Drug Administration , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Abandono do Hábito de Fumar/métodos , Abandono do Hábito de Fumar/psicologia , Prevenção do Hábito de Fumar , Estados Unidos/epidemiologia , Adulto Jovem
11.
Am J Public Health ; 104(12): 2271-8, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25322308

RESUMO

The prevailing approach to improving population health focuses on shifting population means through a few targeted and universal interventions. The success of this approach for eliminating health disparities depends on an assumption about the distribution of demand for such interventions. We explored whether long tail thinking from business might yield greater progress in eliminating disparities. We examined 2011 to 2013 data from 513 state and local health agency representatives in 47 states who used an online system to create 4351 small media and client reminder products promoting colorectal cancer screening. Products in the long tail were more likely to target minority groups with higher rates of colorectal cancer and lower rates of screening than Whites. Long tail thinking could help improve the public's health and eliminate disparities.


Assuntos
Neoplasias Colorretais/diagnóstico , Disparidades em Assistência à Saúde , Programas de Rastreamento , Prática de Saúde Pública , Sistemas de Alerta , Comportamento de Escolha , Detecção Precoce de Câncer , Acesso aos Serviços de Saúde , Humanos , Ontário , Desenvolvimento de Programas , Estados Unidos , Populações Vulneráveis
12.
Milbank Q ; 92(1): 40-62, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24597555

RESUMO

CONTEXT: Implementing the Affordable Care Act (ACA) in 2014 will require effective enrollment and outreach efforts to previously uninsured individuals now eligible for coverage. METHODS: From 1996 to 2013, the Health Communication Research Laboratory conducted more than 40 original studies with more than 30,000 participants to learn how to improve the reach to and effectiveness of health information for low-income and racial/ethnic minority populations. We synthesized the findings from this body of research and used them to inform current challenges in implementing the ACA. FINDINGS: We found empirical support for 5 recommendations regarding partnerships, outreach, messages and messengers, life priorities of low-income individuals and families, and the information environment. We translated these into 12 action steps. CONCLUSIONS: Health communication science can inform the development and execution of strategies to increase the public's understanding of the ACA and to support the enrollment of eligible individuals into Medicaid or the Health Insurance Marketplace.


Assuntos
Comunicação em Saúde/métodos , Trocas de Seguro de Saúde/organização & administração , Disseminação de Informação/métodos , Cobertura do Seguro/organização & administração , Medicaid/organização & administração , Pessoas sem Cobertura de Seguro de Saúde/legislação & jurisprudência , Patient Protection and Affordable Care Act/organização & administração , Prática Clínica Baseada em Evidências/métodos , Humanos , Saúde das Minorias , Pobreza , Estados Unidos
13.
Bull World Health Organ ; 91(6): 426-433B, 2013 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-24052679

RESUMO

OBJECTIVE: To determine whether a women's group intervention involving participatory learning and action has a sustainable and replicable effect on neonatal survival in rural, eastern India. METHODS: From 2004 to 2011, births and neonatal deaths in 36 geographical clusters in Jharkhand and Odisha were monitored. Between 2005 and 2008, these clusters were part of a randomized controlled trial of how women's group meetings involving participatory learning and action influence maternal and neonatal health. Between 2008 and 2011, groups in the original intervention clusters (zone 1) continued to meet to discuss post-neonatal issues and new groups in the original control clusters (zone 2) met to discuss neonatal health. Logistic regression was used to examine neonatal mortality rates after 2008 in the two zones. FINDINGS: Data on 41,191 births were analysed. In zone 1, the intervention's effect was sustained: the cluster-mean neonatal mortality rate was 34.2 per 1000 live births (95% confidence interval, CI: 28.3-40.0) between 2008 and 2011, compared with 41.3 per 1000 live births (95% CI: 35.4-47.1) between 2005 and 2008. The effect of the intervention was replicated in zone 2: the cluster-mean neonatal mortality rate decreased from 61.8 to 40.5 per 1000 live births between two periods: 2006-2008 and 2009-2011 (odds ratio: 0.69, 95% CI: 0.57-0.83). Hygiene during delivery, thermal care of the neonate and exclusive breastfeeding were important factors. CONCLUSION: The effect of participatory women's groups on neonatal survival in rural India, where neonatal mortality is high, was sustainable and replicable.


Assuntos
Mortalidade Infantil , População Rural , Sobrevida , Mulheres/educação , Humanos , Índia , Recém-Nascido , Estudos Prospectivos
14.
Int J Epidemiol ; 42(2): 520-32, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23509239

RESUMO

Progress towards the Millennium Development Goals (MDGs) has been uneven. Inequalities in child health are large and effective interventions rarely reach the most in need. Little is known about how to reduce these inequalities. We describe and explain the equity impact of a women's group intervention in India that strongly reduced the neonatal mortality rate (NMR) in a cluster-randomised trial. We conducted secondary analyses of the trial data, obtained through prospective surveillance of a population of 228,186. The intervention effects were estimated separately, through random effects logistic regression, for the most and less socio-economically marginalised groups. Among the most marginalised, the NMR was 59% lower in intervention than in control clusters in years 2 and 3 (70%, year 3); among the less marginalised, the NMR was 36% lower (35%, year 3). The intervention effect was stronger among the most than among the less marginalised (P-value for difference = 0.028, years 2-3; P-value for difference = 0.009, year 3). The stronger effect was concentrated in winter, particularly for early NMR. There was no effect on the use of health-care services in either group, and improvements in home care were comparable. Participatory community interventions can substantially reduce socio-economic inequalities in neonatal mortality and contribute to an equitable achievement of the unfinished MDG agenda.


Assuntos
Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde , Mortalidade Infantil/tendências , Fatores Socioeconômicos , Participação da Comunidade , Pesquisa Participativa Baseada na Comunidade , Feminino , Humanos , Índia/epidemiologia , Recém-Nascido , Masculino , Vigilância da População , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto
15.
Am J Prev Med ; 43(6 Suppl 5): S425-34, 2012 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-23157761

RESUMO

BACKGROUND: Callers to 2-1-1 have greater need for and lesser use of cancer control services than other Americans. Integrating cancer risk assessment and referrals to preventive services into 2-1-1 systems is both feasible and acceptable to callers. PURPOSE: To determine whether callers will act on these referrals. METHODS: In a randomized trial, 2-1-1 callers (n=1200) received standard service and those with at least one cancer risk factor or need for screening were assigned to receive verbal referrals only, verbal referrals + a tailored reminder mailed to their home, or verbal referrals + a telephone health coach/navigator. All data were collected from June 2010 to March 2012 and analyzed in March and April 2012. RESULTS: At 1-month follow-up, callers in the navigator condition were more likely to report having contacted a cancer control referral than those receiving tailored reminders or verbal referrals only (34% vs 24% vs 18%, respectively; n=772, p<0.0001). Compared to verbal referrals only, navigators were particularly effective in getting 2-1-1 callers to contact providers for mammograms (OR=2.10, 95% CI=1.04, 4.22); Paps (OR=2.98, 95% CI=1.18, 7.54); and smoking cessation (OR=2.07, 95% CI=1.14, 3.74). CONCLUSIONS: Given the extensive reach of 2-1-1s and the elevated risk profile of their callers, even modest response rates could have meaningful impact on population health if proactive health referrals were implemented nationally.


Assuntos
Serviços de Informação/organização & administração , Neoplasias/diagnóstico , Serviços Preventivos de Saúde/métodos , Encaminhamento e Consulta/organização & administração , Adulto , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Masculino , Mamografia/estatística & dados numéricos , Programas de Rastreamento/estatística & dados numéricos , Neoplasias/prevenção & controle , Medição de Risco/métodos , Fatores de Risco , Abandono do Hábito de Fumar/estatística & dados numéricos , Telefone
16.
Am J Prev Med ; 43(6 Suppl 5): S469-74, 2012 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-23157767

RESUMO

BACKGROUND: Delivering health information and referrals through 2-1-1 is promising, but these systems need efficient ways of identifying callers at increased risk. PURPOSE: This study explores the utility of using 2-1-1 service request data to predict callers' cancer control needs. METHODS: Using data from a large sample of callers (N=4101) to United Way 2-1-1 Missouri, logistic regression was used to examine the relationship between caller demographics and type of service request, and cancer control needs. RESULTS: Of six types of service requests examined, three were associated with one or more cancer control needs. Two of the service request types were associated also with health insurance status. CONCLUSIONS: Findings suggest routinely collected 2-1-1 service request data may be useful in helping to efficiently identify callers with specific cancer prevention and control needs. However, to apply this approach in 2-1-1 systems across the country, further research and ongoing surveillance is necessary.


Assuntos
Necessidades e Demandas de Serviços de Saúde , Serviços de Informação/organização & administração , Neoplasias/prevenção & controle , Encaminhamento e Consulta/organização & administração , Adolescente , Adulto , Feminino , Humanos , Serviços de Informação/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Missouri , Encaminhamento e Consulta/estatística & dados numéricos , Fatores de Risco , Telefone , Adulto Jovem
17.
Am J Prev Med ; 43(6 Suppl 5): S483-9, 2012 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-23157769

RESUMO

BACKGROUND: In times of crises, 2-1-1 serves as a lifeline in many ways. These crises often cause a spike in call volume that can challenge 2-1-1's ability to meet its service quality standards. For researchers gathering data through 2-1-1s, a sudden increase in call volume might reduce accrual as 2-1-1 has less time to administer study protocols. Research activities imbedded in 2-1-1 systems may affect directly 2-1-1 service quality indicators. PURPOSE: Using data from a 2-1-1 research collaboration, this paper examines the impact of crises on call volume to 2-1-1, how call volume affects research participant accrual through 2-1-1, and how research recruitment efforts affect 2-1-1 service quality indicators. METHODS: t-tests were used to examine the effect of call volume on research participant accrual. Linear and logistic regressions were used to examine the effect of research participant accrual on 2-1-1 service quality indicators. Data were collected June 2010-December 2011; data were analyzed in 2012. RESULTS: Findings from this collaboration suggest that crises causing spikes in call volume adversely affect 2-1-1 service quality indicators as well as accrual of research participants. Administering a brief (2-3 minute) health risk assessment did not affect service quality negatively, but administering a longer (15-18 minute) survey had a modest adverse effect on these indicators. CONCLUSIONS: In 2-1-1 research collaborations, both partners need to understand the dynamic relationship among call volume, research accrual, and service quality and adjust expectations accordingly. If research goals include administering a longer survey, increased staffing of 2-1-1 call centers may be needed to avoid compromising service quality.


Assuntos
Serviços de Informação/organização & administração , Seleção de Pacientes , Indicadores de Qualidade em Assistência à Saúde , Pesquisa/organização & administração , Comportamento Cooperativo , Coleta de Dados/métodos , Desastres , Humanos , Serviços de Informação/normas , Serviços de Informação/estatística & dados numéricos , Modelos Lineares , Modelos Logísticos , Medição de Risco/métodos , Telefone , Fatores de Tempo
18.
J Affect Disord ; 138(3): 277-86, 2012 May.
Artigo em Inglês | MEDLINE | ID: mdl-22342117

RESUMO

BACKGROUND: Maternal common mental disorders are prevalent in low-resource settings and have far-reaching consequences for maternal and child health. We assessed the prevalence and predictors of psychological distress as a proxy for common mental disorders among mothers in rural Jharkhand and Orissa, eastern India, where over 40% of the population live below the poverty line and access to reproductive and mental health services is low. METHOD: We screened 5801 mothers around 6 weeks after delivery using the Kessler-10 item scale, and identified predictors of distress using multiple hierarchical logistic regression. RESULTS: 11.5% (95% CI: 10.7-12.3) of mothers had symptoms of distress (K10 score >15). High maternal age, low asset ownership, health problems in the antepartum, delivery or postpartum periods, caesarean section, an unwanted pregnancy for the mother, small perceived infant size and a stillbirth or neonatal death were all independently associated with an increased risk of distress. The loss of an infant or an unwanted pregnancy increased the risk of distress considerably (AORs: 7.06 95% CI: 5.51-9.04 and 1.49, 95% CI: 1.12-1.97, respectively). LIMITATIONS: We did not collect data on antepartum depression, domestic violence or a mother's past birth history, and were therefore unable to examine the importance of these factors as predictors of psychological distress. CONCLUSIONS: Mothers living in underserved areas of India who experience infant loss, an unwanted pregnancy, health problems in the perinatal and postpartum periods and socio-economic disadvantage are at increased risk of distress and require access to reproductive healthcare with integrated mental health interventions.


Assuntos
Transtornos Mentais/epidemiologia , Mães/psicologia , Estresse Psicológico/epidemiologia , Adolescente , Adulto , Estudos Transversais , Feminino , Humanos , Índia/epidemiologia , Acontecimentos que Mudam a Vida , Modelos Logísticos , Mães/estatística & dados numéricos , Pobreza , Prevalência , Ensaios Clínicos Controlados Aleatórios como Assunto , População Rural , Adulto Jovem
19.
Trials ; 12: 182, 2011 Jul 25.
Artigo em Inglês | MEDLINE | ID: mdl-21787392

RESUMO

BACKGROUND: Around a quarter of the world's neonatal and maternal deaths occur in India. Morbidity and mortality are highest in rural areas and among the poorest wealth quintiles. Few interventions to improve maternal and newborn health outcomes with government-mandated community health workers have been rigorously evaluated at scale in this setting.The study aims to assess the impact of a community mobilisation intervention with women's groups facilitated by ASHAs to improve maternal and newborn health outcomes among rural tribal communities of Jharkhand and Orissa. METHODS/DESIGN: The study is a cluster-randomised controlled trial and will be implemented in five districts, three in Jharkhand and two in Orissa. The unit of randomisation is a rural cluster of approximately 5000 population. We identified villages within rural, tribal areas of five districts, approached them for participation in the study and enrolled them into 30 clusters, with approximately 10 ASHAs per cluster. Within each district, 6 clusters were randomly allocated to receive the community intervention or to the control group, resulting in 15 intervention and 15 control clusters. Randomisation was carried out in the presence of local stakeholders who selected the cluster numbers and allocated them to intervention or control using a pre-generated random number sequence. The intervention is a participatory learning and action cycle where ASHAs support community women's groups through a four-phase process in which they identify and prioritise local maternal and newborn health problems, implement strategies to address these and evaluate the result. The cycle is designed to fit with the ASHAs' mandate to mobilise communities for health and to complement their other tasks, including increasing institutional delivery rates and providing home visits to mothers and newborns. The trial's primary endpoint is neonatal mortality during 24 months of intervention. Additional endpoints include home care practices and health care-seeking in the antenatal, delivery and postnatal period. The impact of the intervention will be measured through a prospective surveillance system implemented by the project team, through which mothers will be interviewed around six weeks after delivery. Cost data and qualitative data are collected for cost-effectiveness and process evaluations. STUDY REGISTRATION: ISRCTN: ISRCTN31567106.


Assuntos
Serviços de Saúde da Criança/organização & administração , Análise por Conglomerados , Serviços de Saúde Comunitária/organização & administração , Redes Comunitárias/organização & administração , Serviços de Saúde Materna/organização & administração , Área Carente de Assistência Médica , Projetos de Pesquisa , Serviços de Saúde Rural/organização & administração , Serviços de Saúde da Criança/economia , Serviços de Saúde Comunitária/economia , Redes Comunitárias/economia , Análise Custo-Benefício , Países em Desenvolvimento , Feminino , Comportamentos Relacionados com a Saúde , Custos de Cuidados de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Prioridades em Saúde , Humanos , Índia , Mortalidade Infantil , Recém-Nascido , Serviços de Saúde Materna/economia , Mortalidade Materna , Objetivos Organizacionais , Aceitação pelo Paciente de Cuidados de Saúde , Educação de Pacientes como Assunto , Gravidez , Estudos Prospectivos , Serviços de Saúde Rural/economia , Fatores de Tempo
20.
Patient Educ Couns ; 81 Suppl: S6-14, 2010 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-21071167

RESUMO

OBJECTIVE: Compare effects of narrative and informational videos on use of mammography, cancer-related beliefs, recall of core content and a range of reactions to the videos. METHOD: African American women (n=489) ages 40 and older were recruited from low-income neighborhoods in St. Louis, MO and randomly assigned to watch a narrative video comprised of stories from African American breast cancer survivors (Living Proof) or a content-equivalent informational video using a more expository and didactic approach (Facts for Life). Effects were measured immediately post-exposure and at 3- and 6-month follow-up. RESULTS: The narrative video was better liked, enhanced recall, reduced counterarguing, increased breast cancer discussions with family members and was perceived as more novel. Women who watched the narrative video also reported fewer barriers to mammography, more confidence that mammograms work, and were more likely to perceive cancer as an important problem affecting African Americans. Use of mammography at 6-month follow-up did not differ for the narrative vs. informational groups overall (49% vs. 40%, p=.20), but did among women with less than a high school education (65% vs. 32%, p<.01), and trended in the same direction for those who had no close friends or family with breast cancer (49% vs. 31%, p=.06) and those who were less trusting of traditional cancer information sources (48% vs. 30%, p=.06). CONCLUSIONS: Narrative forms of communication may increase the effectiveness of interventions to reduce cancer health disparities. PRACTICE IMPLICATIONS: Narratives appear to have particular value in certain population sub-groups; identifying these groups and matching them to specific communication approaches may increase effectiveness.


Assuntos
Afro-Americanos , Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/etnologia , Mamografia , Narração , Educação de Pacientes como Assunto/métodos , Gravação de Videoteipe , Adulto , Neoplasias da Mama/psicologia , Escolaridade , Feminino , Seguimentos , Conhecimentos, Atitudes e Prática em Saúde , Promoção da Saúde/métodos , Disparidades em Assistência à Saúde , Humanos , Pessoa de Meia-Idade , Missouri , Pobreza
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