Social determinants of antibiotic misuse: a qualitative study of community members in Haryana, India.

BACKGROUND: Antibiotic resistance is a global public health crisis. In India alone, multi-drug resistant organisms are responsible for over 58,000 infant deaths each year. A major driver of drug resistance is antibiotic misuse, which is a pervasive phenomenon worldwide. Due to a shortage of trained doctors, access to licensed allopathic doctors is limited in India's villages. Pharmacists and unlicensed medical providers are commonly the primary sources of healthcare. Patients themselves are also key participants in the decision to treat an illness with antibiotics. Thus, better understanding of the patient-provider interactions that may contribute to patients' inappropriate use of antibiotics is critical to reducing these practices in urban and rural Indian villages. METHODS: We conducted a qualitative study of the social determinants of antibiotic use among twenty community members in Haryana, India. Semi-structured interview questions focused on two domains: typical antibiotic use and the motivation behind these practices. A cross-sectional pilot survey investigated the same twenty participants' understanding and usage of antibiotics. Interview and open-ended survey responses were translated, transcribed, and coded for themes. RESULTS: Antibiotics and the implications of their misuse were poorly understood by study participants. No participant was able to correctly define the term antibiotics. Participants with limited access to an allopathic doctor, either for logistic or economic reasons, were more likely to purchase medications directly from a pharmacy without a prescription. Low income participants were also more likely to prematurely stop antibiotics after symptoms subsided. Regardless of income, participants were more likely to seek an allopathic doctor for their children than for themselves. CONCLUSIONS: The prevalent misuse of antibiotics among these community members reinforces the importance of conducting research to develop effective strategies for stemming the tide of antibiotic resistance in India's villages.

Evaluation of a theory-driven e-learning intervention for future oral healthcare providers on secondary prevention of disordered eating behaviors.

Oral healthcare providers have a clinical opportunity for early detection of disordered eating behaviors because they are often the first health professionals to observe overt oral and physical signs. Curricula regarding early recognition of this oral/systemic medical condition are limited in oral health educational programs. Web-based learning can supplement and reinforce traditional learning and has the potential to develop skills. The study purpose was to determine the efficacy of a theory-driven Web-based training program to increase the capacity of oral health students to perform behaviors related to the secondary prevention of disordered eating behaviors. Using the Reach, Effectiveness, Adoption, Implementation and Maintenance evaluation framework, a longitudinal group-randomized controlled trial involving 27 oral health classes from 12 oral health education programs in the United States was implemented to assess the efficacy of the Web-based training on attitudes, knowledge, self-efficacy and skills related to the secondary prevention of disordered eating behaviors. Mixed-model analysis of covariance indicated substantial improvements among students in the intervention group (effect sizes: 0.51-0.83) on all six outcomes of interest. Results suggest that the Web-based training program may increase the capacity of oral healthcare providers to deliver secondary prevention of disordered eating behaviors. Implications and value of using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework are discussed.

Creating successful price and placement strategies for social marketing.

A successful marketing strategy includes the design of a marketing mix with the right combination of products, offered at the right price, in the right place, and then promoted in such a way that makes it easy and rewarding for the individual to change his or her behavior. A price is incurred in exchange for receiving a bundle of benefits. The social marketer can use various pricing tactics to make the desired behavior appear to have fewer costs and more benefits while making the undesired behavior to have less benefit and greater cost. Place is where and when the target population will perform the desired behavior, purchase or obtain a tangible product, and/or receive associated services. Involving partners in the placement strategy can make products more accessible and increase opportunities for people to perform a behavior. Strategies for making the product available at a desirable price and in places that are convenient are integral to the overall social marketing plan to facilitate behavior change.

Using pretesting to ensure your messages and materials are on strategy.

Pretesting is an important demonstration of understanding consumers' wants and preferences. This evolving, data-driven process provides opportunity for ensuring time, effort, and valuable resources are not wasted. The purpose of this article is to clarify the process of pretesting, why one should pretest, common mistakes, and pretesting on a shoestring budget.

The use of portfolios in coordinated school health programs: benefits and challenges to implementation.

BACKGROUND: Coordinated school health programs (CSHP) frequently struggle with how to adequately evaluate implementation. The CSHP framework provides flexibility in how it is implemented; however, this flexibility makes it a challenge to effectively evaluate. Portfolios have been used as a technique for evaluating progress and achievement. This article describes the development and implementation of a CSHP portfolio and examines the perceptions of school personnel who have used CSHP portfolios. METHODS: This study employed content analysis and key informant interviews. Two elementary, 4 middle, and 2 high schools in Florida participated. RESULTS: Portfolios (N = 5) contained rich descriptions and program artifacts documenting each school's CSHP goals and activities. Key informant interviews (N = 14) revealed that school personnel found value in completing CSHP portfolios. CSHP portfolios were described as helpful in assessing progress, facilitating transition with new members, and building support for their efforts. Barriers to portfolio development included lack of time, money, and human resources. CONCLUSIONS: This study found the use of portfolios in documenting the implementation of the CSHP feasible and useful for school personnel. Portfolios provide a rich description of CSHP activities that may not be apparent through traditional program reports used for evaluation. As portfolios continue to be used in implementing CSHP, they may be viewed as a best process for CSHP implementation and a key element in the evaluation of CSHP.

Competition: a social marketer's friend or foe?

In public health social marketing, is there such a thing as "healthy competition," or is the term an oxymoron? The primary focus of this article is on a type of competition that may not often be considered by public health social marketers--competition from other marketing activities that exist in the marketplace in which your intervention is operating. This could also be termed "promotion" competition. The purpose of this article is to briefly review promotion competition and then review competitive factors that can impact a social marketing initiative's success, examine how to conduct a useful competitive analysis, and offer strategies for maximizing the benefits and minimizing the negative implications of competition on your efforts.

Community-based prevention marketing: organizing a community for health behavior intervention.

This article describes the application and refinement of community-based prevention marketing (CBPM), an example of community-based participatory research that blends social marketing theories and techniques and community organization principles to guide voluntary health behavior change. The Florida Prevention Research Center has worked with a community coalition in Sarasota County, Florida to define locally important health problems and issues and to develop responsive health-promotion interventions. The CBPM framework has evolved as academic and community-based researchers have gained experience applying it. Community boards can use marketing principles to design evidence-based strategies for addressing local public health concerns. Based on 6 years of experience with the "Believe in All Your Possibilities" program, lessons learned that have led to revision and improvement of the CBPM framework are described.

What drives inappropriate antibiotic dispensing? A mixed-methods study of pharmacy employee perspectives in Haryana, India.

OBJECTIVES: There are only 0.70 licensed physicians per 1000 people in India. Thus, pharmacies are a primary source of healthcare and patients often seek their services directly, especially in village settings. However, there is wide variability in a pharmacy employee's training, which contributes to inappropriate antibiotic dispensing and misuse. These practices increase the risk of antibiotic resistance and poor patient outcomes. This study seeks to better understand the factors that drive inappropriate antibiotic dispensing among pharmacy employees in India's village communities. DESIGN: We conducted a mixed-methods study of the antibiotic dispensing practices, including semistructured interviews and a pilot cross-sectional Knowledge, Attitudes and Practice survey. All data were transcribed, translated from Hindi into English, and coded for themes. SETTING: Community pharmacies in villages in Haryana, India. PARTICIPANTS: We recruited 24 community pharmacy employees (all male) by convenience sampling. Participants have a range of characteristics regarding village location, monthly income, baseline antibiotic knowledge, formal education and licensure. RESULTS: 75% of pharmacy employees in our study were unlicensed practitioners, and the majority had very limited understanding of antibiotic resistance. Furthermore, only half could correctly define the term antibiotics. All reported that at times they dispensed antibiotics without a prescription. This practice was more common when treating patients who had limited access to a licensed physician because of economic or logistic reasons. Many pharmacy workers also felt pressure to provide shortened medication courses to poorer clientele, and often dispensed only 1 or 2 days' worth of antibiotics. Such patients rarely returned to the pharmacy for the complete course. CONCLUSIONS: This study highlights the need for short-term, intensive training programmes on antibiotic prescribing and resistance that can be disseminated to village pharmacies. Programme development should take into account the realities of working with poor clientele, especially in areas of limited healthcare access.

Barriers and facilitators to infection control at a hospital in northern India: a qualitative study.

BACKGROUND: Hospital acquired infections occur at higher rates in low- and middle-income countries, like India, than in high-income countries. Effective implementation of infection control practices is crucial to reducing the transmission of hospital acquired infections at hospitals worldwide. Yet, no comprehensive assessments of the barriers to sustained, successful implementation of hospital interventions have been performed in Indian healthcare settings to date. The Systems Engineering Initiative for Patient Safety (SEIPS) model examines problems through the lens of interactions between people and systems. It is a natural fit for investigating the behavioral and systematic components of infection control practices. METHODS: We conducted a qualitative study to assess the facilitators and barriers to infection control practices at a 1250 bed tertiary care hospital in Haryana, northern India. Twenty semi-structured interviews of nurses and physicians, selected by convenience sampling, were conducted in English using an interview guide based on the SEIPS model. All interview data was subsequently transcribed and coded for themes. RESULTS: Person, task, and organizational level factors were the primary barriers and facilitators to infection control at this hospital. Major barriers included a high rate of nursing staff turnover, time spent training new staff, limitations in language competency, and heavy clinical workloads. A well developed infection control team and an institutional climate that prioritizes infection control were major facilitators. CONCLUSIONS: Institutional support is critical to the effective implementation of infection control practices. Prioritizing resources to recruit and retain trained, experienced nursing staff is also essential.

Prevention Research Centers: contributions to updating the public health workforce through training.

Because public health is a continually evolving field, it is essential to provide ample training opportunities for public health professionals. As a natural outgrowth of the Centers for Disease Control and Prevention's Prevention Research Centers Program, training courses of many types have been developed for public health practitioners working in the field. This article describes three of the Prevention Research Center training program offerings: Evidence-Based Public Health, Physical Activity and Public Health for Practitioners, and Social Marketing. These courses illustrate the commitment of the Prevention Research Centers Program to helping create a better trained public health workforce, thereby enhancing the likelihood of improving public health.

Conducting web-based survey research: a lesson in internet designs.

OBJECTIVES: To examine the tacit knowledge resulting from designing a complex Web site to facilitate administration of an Internet-based survey. METHODS: Formative methods guided studying the feasibility of conducting an online survey using versions of the Keirsey Temperament Sorter II and the National College Health Risk Behavior Survey. RESULTS: Web-site design software and pilot testing were critical to success. Incorporating the target audience as consumers in both Web site development and formative evaluation simplified data collection and analysis. CONCLUSIONS: Online instrumentation used in survey research is both practical and desirable. Future refinements are necessary, but improved designs can emanate from this particular effort.

Cigarette use in 6th through 10th grade: the Sarasota County Demonstration Project.

OBJECTIVES: To identify factors associated with cigarette smoking in the 6th-grade through 10th-grade youth population of Sarasota County, Florida. METHODS: A closed-ended, quantitative survey was completed by 2004 youth and used to extract population-specific data on the correlates of cigarette use. RESULTS: A range of factors influence cigarette use including self-efficacy to refuse offers of cigarettes, perceived emotional benefits, and perceived maternal disapproval of smoking. CONCLUSIONS: Results underscore the need for multiple-component interventions. This study is unique in that it represents population-specific research in which community partners are using the findings to develop community-specific prevention marketing interventions.

California school board members' perceptions of factors influencing school nutrition policy.

Enactment and enforcement of school nutrition policies represent key components in adolescent overweight and obesity prevention. This study determined: 1) California school board members' attitudes, perceptions, and motivations related to enactment of policies that support healthy eating in schools; and 2) barriers to adopting school policies that support healthy eating. To understand board members' decision-making process, key informant interviews were conducted and a survey was administered to 404 school board members. Though school board members care about the well-being of pupils, competing priorities limit the extent to which nutrition issues get addressed at board meetings. Members' decisions center primarily around academic achievement issues, yet they are interested in nutrition's overall impact on children's health and academic achievement.

Factors related to alcohol use among 6th through 10th graders: the Sarasota County Demonstration Project.

Alcohol consumption by youth can produce negative health outcomes. This study identified correlates of lifetime alcohol use, recent alcohol use, and binge drinking among youth in sixth through 10th grade (n = 2,004) in Sarasota County, Fla. Results from a closed-ended, quantitative survey acknowledged a range of personal, social, and environmental influences. Breadth of these influences supports a need for multifaceted, community-based interventions for effective prevention of youth alcohol use. This study was unique because it represents population-specific research in which community partners are using the findings to develop community-specific social marketing interventions to prevent underage drinking and promote alternative behaviors.

Randomized trial of two e-learning programs for oral health students on secondary prevention of eating disorders.

The purpose of this study was to test whether an interactive, web-based training program is more effective than an existing, flat-text, e-learning program at improving oral health students' knowledge, motivation, and self-efficacy to address signs of disordered eating behaviors with patients. Eighteen oral health classes of dental and dental hygiene students were randomized to either the Intervention (interactive program; n=259) or Alternative (existing program; n=58) conditions. Hierarchical linear modeling assessed for posttest differences between groups while controlling for baseline measures. Improvement among Intervention participants was superior to those who completed the Alternative program for three of the six outcomes: benefits/barriers, self-efficacy, and skills-based knowledge (effect sizes ranging from 0.43 to 0.87). This study thus suggests that interactive training programs may be better than flat-text e-learning programs for improving the skills-based knowledge and self-efficacy necessary for behavior change.

Developing and pretesting case studies in dental and dental hygiene education: using the diffusion of innovations model.

Case-based learning offers exposure to clinical situations that health professions students may not encounter in their training. The purposes of this study were to apply the Diffusion of Innovations conceptual framework to 1) identify characteristics of case studies that would increase their adoption among dental and dental hygiene faculty members and 2) develop and pretest interactive web-based case studies on sensitive oral-systemic health issues. The formative study spanned two phases using mixed methods (Phase 1: eight focus groups and four interviews; Phase 2: ten interviews and satisfaction surveys). Triangulation of quantitative and qualitative data revealed the following positive attributes of the developed case studies: relative advantage of active learning and modeling; compatibility with a variety of courses; observability of case-related knowledge and skills; independent learning; and modifiability for use with other oral-systemic health issues. These positive attributes are expected to increase the likelihood that dental and dental hygiene faculty members will adopt the developed case study once it is available for use. The themes identified in this study could be applied to the development of future case studies and may provide broader insight that might prove useful for exploring differences in case study use across dental and dental hygiene curricula.

Frequent fliers, school phobias, and the sick student: school health personnel's perceptions of students who refuse school.

BACKGROUND: This study explored school personnel's perceptions of school refusal, as it has been described as a "common educational and public health problem" that is less tolerated due to increasing awareness of the potential socioeconomic consequences of this phenomenon. METHODS: In-depth interviews were conducted with school personnel at the middle school (N = 42), high school (N = 40), and district levels (N = 10). The findings focus on emergent themes from interviews with school health personnel (N = 12), particularly those themes related to their perceptions of and role in working with school-refusing students. RESULTS: Personnel, especially school health services staff, constructed a typification of the school-refusing student as "the sick student," which conceptualized student refusal due to reasons related to illness. Personnel further delineated sick students by whether they considered the illness legitimate. School health personnel referenced the infamous "frequent fliers" and "school phobics" within this categorization of students. Overarching dynamics of this typification included parental control, parental awareness, student locus of control, blame, and victim status. These typifications influenced how personnel reacted to students they encountered, particularly in deciding which students need "help" versus "discipline," thus presenting implications for students and screening of students. CONCLUSIONS: Overall, findings suggest school health personnel play a pivotal role in screening students who are refusing school as well as keeping students in school, underscoring policy that supports an increased presence of school health personnel. Recommendations for school health, prevention, and early intervention include the development of screening protocols and staff training.