Barriers and facilitators to the integration of depression services in primary care in Vietnam: a mixed methods study.

BACKGROUND: Although the prevalence of depression in Vietnam is on par with global rates, services for depression are limited. The government of Vietnam has prioritized enhancing depression care through primary healthcare (PHC) and efforts are currently underway to test and scale-up psychosocial interventions throughout the country. With these initiatives in progress, it is important to understand implementation factors that might influence the successful integration of depression services into PHC. As the implementers of these new interventions, primary care providers (PHPs) are well placed to provide important insight into implementation factors affecting the integration of depression services into PHC. This mixed-methods study examines factors at the individual, organizational and structural levels that may act as barriers and facilitators to the integration of depression services into PHC in Vietnam from the perspective of PHPs. METHODS: Data collection took place in Hanoi, Vietnam in 2014. We conducted semi-structured interviews with PHPs (n = 30) at commune health centres and outpatient clinics in one rural and one urban district of Hanoi. Theoretical thematic analysis was used to analyse interview data. We administered an online survey to PHPs at n = 150 randomly selected communes across Hanoi. N = 226 PHPs responded to the survey. We used descriptive statistics to describe the study variables acting as barriers and facilitators and used a chi-square test of independence to indicate statistically significant (p < .05) associations between study variables and the profession, location and gender of PHPs. RESULTS: Individual-level barriers include low level of knowledge and familiarity with depression among PHPs. Organizational barriers include low resource availability in PHC and low managerial discretion. Barriers at the structural level include limited mental health training among all PHPs and the existing programmatic structure of PHC in Vietnam, which sets mental health apart from general services. Facilitators at the individual level include positive attitudes among PHPs towards people with depression and interest in undergoing enhanced training in depression service delivery. CONCLUSIONS: While facilitating factors at the individual level are encouraging, considerable barriers at the structural level must be addressed to ensure the successful integration of depression services into PHC in Vietnam.

A novel integration of online and flipped classroom instructional models in public health higher education.

BACKGROUND: In 2013, a cohort of public health students participated in a 'flipped' Environmental and Occupational Health course. Content for the course was delivered through NextGenU.org and active learning activities were carried out during in-class time. This paper reports on the design, implementation, and evaluation of this novel approach. METHODS: Using mixed-methods, we examined learning experiences and perceptions of the flipped classroom model and assessed changes in students' self-perceived knowledge after participation in the course. We used pre- and post-course surveys to measure changes in self-perceived knowledge. The post-course survey also included items regarding learning experiences and perceptions of the flipped classroom model. We also compared standard course review and examination scores for the 2013 NextGenU/Flipped Classroom students to previous years when the course was taught with a lecture-based model. We conducted a focus group session to gain more in-depth understanding of student learning experiences and perceptions. RESULTS: Students reported an increase in knowledge and survey and focus group data revealed positive learning experiences and perceptions of the flipped classroom model. Mean examination scores for the 2013 NextGenU/Flipped classroom students were 88.8% compared to 86.4% for traditional students (2011). On a scale of 1-5 (1 = lowest rank, 5 = highest rank), the mean overall rating for the 2013 NextGenU/Flipped classroom students was 4.7/5 compared to prior years' overall ratings of 3.7 (2012), 4.3 (2011), 4.1 (2010), and 3.9 (2009). Two key themes emerged from the focus group data: 1) factors influencing positive learning experience (e.g., interactions with students and instructor); and 2) changes in attitudes towards environmental and occupation health (e.g., deepened interest in the field). CONCLUSION: Our results show that integration of the flipped classroom model with online NextGenU courses can be an effective innovation in public health higher education: students achieved similar examination scores, but NextGenU/Flipped classroom students rated their course experience more highly and reported positive learning experiences and an increase in self-perceived knowledge. These results are promising and suggest that this approach warrants further consideration and research.

Where are the NGOs and why? The distribution of health and development NGOs in Bolivia.

BACKGROUND: The presence and influence of nongovernmental organizations (NGOs) in the landscape of global health and development have dramatically increased over the past several decades. The distribution of NGO activity and the ways in which contextual factors influence the distribution of NGO activity across geographies merit study. This paper explores the distribution of NGO activity, using Bolivia as a case study, and identifies local factors that are related to the distribution of NGO activity across municipalities in Bolivia. METHODS: The research question is addressed using a geographic information system (GIS) and multiple regression analyses of count data. We used count data of the total number of NGO projects across Bolivian municipalities to measure NGO activity both in general and in the health sector specifically and national census data for explanatory variables of interest. RESULTS: This study provides one of the first empirical analyses exploring factors related to the distribution of NGO activity at the national scale. Our analyses show that NGO activity in Bolivia, both in general and health-sector specific, is distributed unevenly across the country. Results indicate that NGO activity is related to population size, extent of urbanization, size of the indigenous population, and health system coverage. Results for NGO activity in general and health-sector specific NGO activity were similar. CONCLUSIONS: The uneven distribution of NGO activity may suggest a lack of co-ordination among NGOs working in Bolivia as well as a lack of co-ordination among NGO funders. Co-ordination of NGO activity is most needed in regions characterized by high NGO activity in order to avoid duplication of services and programmes and inefficient use of limited resources. Our findings also indicate that neither general nor health specific NGO activity is related to population need, when defined as population health status or education level or poverty levels. Considering these results we discuss broader implications for global health and development and make several recommendations relevant for development and health practice and research.

Antibiotic knowledge and self-care for acute respiratory tract infections in Mexico.

OBJECTIVE: To examine knowledge of and self-treatment with antibiotics among medically-insured adults in Mexico. MATERIALS AND METHODS: We conducted a cross-sectional, interviewer-administered survey among 101 adult patients seeking care for acute respiratory tract infections in a family medicine clinic in Mexico. Knowledge scores were calculated as a composite of correct, incorrect and don't know responses. Factors associated with antibiotic knowledge and antibiotic self-treatment were explored with bivariate analyses. RESULTS: 47% of participants were taking antibiotics prior to the visit, 20% were self-treating. Antibiotic knowledge was highly variable. Many participants believed common non-antibiotic treatments for colds and coughs were antibiotics, such as ambroxol (45%), Desenfriol (45%) and paracetamol (44%). Older participants (>40 years) had better knowledge scores. DISCUSSION: Self-treatment with and misperceptions about antibiotics are common among medically insured adults seeking medical attention in Mexico.

Annual gatherings as an integrated knowledge translation strategy to support local and traditional food systems within and across Indigenous community contexts: a qualitative study.

Integrated knowledge translation (IKT) and community-based participatory research (CBPR) are recognized as effective approaches when Indigenous and non-Indigenous partners work together to focus on a common goal. The "Learning Circles: Local Healthy Food to School" (LC:LHF2S) study supported the development and implementation of Learning Circles (LC) in 4 Canadian Indigenous communities with the goal of improving local, community-based healthy food systems. Critical to the research process were annual gatherings (AG) where diverse stakeholders (researchers, Indigenous community members, and partners) visited each community to share knowledge, experiences, and provide support in the research process. Using a qualitative, descriptive method, this paper explores how the AG supported IKT across partners. Yearly interviews involving 19 total participants (with some participating multiple times across the 4 gatherings) elicited their AG experiences in supporting local LC:LHF2S. Three themes with multiple sub-themes were identified: (a) setting the stage for IKT (importance of in-person gatherings for building relationships across partners, learning from each other), (b) enabling meaningful engagement (aligning research with Indigenous values, addressing tensions and building trust over time, ensuring flexibility, and Indigenous involvement and leadership), and (c) supporting food system action at the local level (building local community engagement and understanding, and integrating support for implementation and scale-up of LC). This paper provides useful and practical examples of the principles of Indigenous-engaged IKT and CBPR in action in healthy, local, and traditional food initiatives. AG are a valuable IKT strategy to contribute to positive, transformative change and ethical research practice within Indigenous communities.

Can experiential-didactic training improve clinical STD practices?

BACKGROUND: High rates of sexually transmitted diseases (STDs) present an ongoing costly public health challenge. One approach to reduce STD transmission is to increase the number of clinicians adopting the Centers for Disease Control and Prevention's STD Treatment Guidelines. This evaluation assesses the effectiveness of a 3-day experiential and didactic training to translate recommendations into practice by increasing clinician knowledge and skills and helping participants anticipate and overcome barriers to implementation. METHODS: Between 2001 and 2004, 110 direct care clinicians from 10 states participated in one of 27 standardized 3-day interactive trainings offered by the Denver STD/human immunodeficiency virus (HIV) Prevention Training Center. STD/HIV knowledge and clinical skills were measured before, immediately after, and 6 months after training. Practice patterns were assessed before training and after 6 months. Structural barriers to implementation were identified 6 months post-training. RESULTS: Trainees demonstrated significant post-training gains in mean knowledge scores immediately post-training (P < 0.001) and 6 months post-training (P = 0.002). After 6 months, self-reported mean skill levels remained significantly improved compared to precourse (P < 0.05) for each of 27 skills including STD risk assessment, clinical examination, diagnosis, and treatment. Self-reported improvement in practice patterns was significant for 23 of 35 practices (P < 0.05) 6 months post-training. Participants indicated that inadequate time (52.9%), facilities/equipment (51.5%), and staffing (47.1%) interfered with implementation of recommended practices. CONCLUSIONS: Experiential-didactic STD/HIV training can modestly improve knowledge, clinical skills, and implementation of STD recommended practices 6 months after training. Further research is needed to identify the impact of improved clinical practices on STD/HIV transmission.

The Use of SMS Text Messaging to Improve the Hospital-to-Community Transition in Patients With Acute Coronary Syndrome (Txt2Prevent): Results From a Pilot Randomized Controlled Trial.

BACKGROUND: Acute coronary syndrome (ACS) is a leading cause of hospital admission in North America. Many patients with ACS experience challenges after discharge that impact their clinical outcomes and psychosocial well-being. SMS text messaging has the potential to provide support to patients during this postdischarge period. OBJECTIVE: This study pilot tested a 60-day SMS text messaging intervention (Txt2Prevent) for patients with ACS. The primary objective was to compare self-management domains between usual care and usual care plus Txt2Prevent. The secondary objectives were to compare medication adherence, health-related quality of life, self-efficacy, and health care resource use between groups. The third objective was to assess the feasibility of the study protocol and the acceptability of the intervention. METHODS: This was a randomized controlled trial with blinding of outcome assessors. We recruited 76 patients with ACS from St. Paul's Hospital in Vancouver, Canada, and randomized them to 1 of 2 groups within 7 days of discharge. The Txt2Prevent program included automated 1-way SMS text messages about follow-up care, self-management, and healthy living. Data were collected during the index admission and at 60 days after randomization. The primary outcome was measured with the Health Education Impact Questionnaire (heiQ). Other outcomes included the EQ-5D-5L, EQ-5D-5L Visual Analog Scale, a modified Sullivan Cardiac Self-Efficacy Scale, and Morisky Medication Adherence Scale scores, and self-reported health care resource use. Analyses of covariance were used to test the effect of group assignment on follow-up scores (controlling for baseline) and were considered exploratory in nature. Feasibility was assessed with descriptive characteristics of the study protocol. Acceptability was assessed with 2 survey questions and semistructured interviews. RESULTS: There were no statistically significant differences between the groups for the heiQ domains (adjusted mean difference [Txt2Prevent minus usual care] for each domain-Health-directed activity: -0.13, 95% CI -0.39 to 0.13, P=.31; Positive and active engagement in life: 0.03, 95% CI -0.19 to 0.25, P=.76; Emotional distress: 0.04, 95% CI -0.22 to 0.29, P=.77; Self-monitoring and insight: -0.14, 95% CI -0.33 to 0.05, P=.15; Constructive attitudes and approaches: -0.10, 95% CI -0.36 to 0.17, P=.47; Skill technique and acquisition: 0.05, 95% CI -0.18 to 0.27, P=.69; Social integration and support: -0.12, 95% CI -0.34 to 0.10, P=.27; and Health services navigation: -0.05, 95% CI -0.29 to 0.19, P=.69). For the secondary outcomes, there were no statistically significant differences in adjusted analyses except in 1 self-efficacy domain (Total plus), where the Txt2Prevent group had lower scores (mean difference -0.36, 95% CI -0.66 to -0.50, P=.03). The study protocol was feasible, but recruitment took longer than expected. Over 90% (29/31 [94%]) of participants reported they were satisfied with the program. CONCLUSIONS: The Txt2Prevent study was feasible to implement; however, although exploratory, there were no differences between the 2 groups in adjusted analyses except for 1 self-efficacy domain. As the intervention appeared acceptable, there is potential in using SMS text messages in this context. The design of the intervention may need to be reconsidered to have more impact on outcome measures. TRIAL REGISTRATION: ClinicalTrials.gov NCT02336919; https://clinicaltrials.gov/ct2/show/NCT02336919. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/resprot.6968.

How do community practitioners decide whether to prescribe antibiotics for acute respiratory tract infections?

BACKGROUND: Overuse of antibiotics in the treatment of acute respiratory tract infection (ARI) contributes to the growing problem of antibiotic-resistant infections. OBJECTIVE: To identify factors that influence community practitioners to prescribe antibiotics and examine how they differ from the recommendations of the Centers for Disease Control and Prevention (CDC) guideline for treatment of ARI. DESIGN: Paper case vignette study using a fractional factorial design. PARTICIPANTS: One hundred one community practitioners and eight faculty members. MAIN MEASUREMENTS: We asked community practitioners to estimate how likely they would be to prescribe antibiotics in each of 20 cases of ARI and then used multiple regression to infer the importance weights of each of nine clinical findings. We then compared practitioners' weights with those of a panel of eight faculty physicians who evaluated the cases following the CDC guidelines rather than their own judgments. MAIN RESULTS: Practitioners prescribed antibiotics in 44.5% of cases, over twice the percentage treated by the panel using the CDC guidelines (20%). In deciding to prescribe antibiotic treatment, practitioners gave little or no weight to patient factors such as whether the patients wanted antibiotics. Although weighting patterns differed among practitioners, the majority (72%) gave the greatest weight to duration of illness. When illness duration was short, the rate of prescribing (20.1%) was the same as the rate of the faculty panel (20%). CONCLUSIONS: Based on hypothetical cases of ARI, community practitioners prescribed antibiotics at twice the rate of faculty following CDC practice guidelines. Practitioners were most strongly influenced by duration of illness. The effect of duration was strongest when accompanied by fever or productive cough, suggesting that these situations would be important areas for practitioner education and further clinical studies.

[Antibiotic use in Mexico: review of problems and policies]. / Uso de antibióticos en México: revisión de problemas y políticas.

The inappropriate use of antibiotics signifies a risk for individual health and a waste of health resources. It triggers the development of antibiotic resistance, which increases expenditures and mortality related to infectious disease, and is hence considered a serious public health problem. The World Health Organization has thus recommended a series of strategies to be included within national pharmaceutical policies. In Mexico, diverse factors related to the inappropriate use of antibiotics have been documented. While the response has been mainly in the form of educational and managerial interventions directed toward physicians in public health services, as well as epidemiological surveillance, there is a paucity of research and interventions focused on consumers, pharmacies, and the private sector. Fundamentally, a comprehensive national strategy for antibiotics is not incorporated into health and pharmaceutical policies.

Face-to-face communication between patients and family physicians in Canada: A scoping review.

OBJECTIVE: Patient-provider communication is critical in primary care. Canada's unique health system, population distribution, and cultural context suggest there is value in addressing the topic in the Canadian context. We conducted a scoping review to synthesize recent Canadian literature to inform practice in primary care settings and identify research agendas for patient-provider communication in Canada. METHODS: Using Arksey and O'Malley's framework we searched four literature databases: Medline, Web of Science, CINAHL and EMBASE. We extracted 21,932 articles published between 2010 and 2017. A total of 108 articles met the inclusion criteria. The articles were analyzed qualitatively using thematic analysis to identify major themes. RESULTS: Four major themes were identified: information sharing, relationships, health system challenges, and development and use of communication tools. CONCLUSION: Our review identified a need for Canadian research regarding: communication in primary care with Aboriginal, immigrant, and rural populations; the impact of medical tourism on primary care; and how to improve communication to facilitate continuity of care. PRACTICE IMPLICATIONS: Challenges providers face in primary care in Canada include: communicating with linguistically and culturally diverse populations; addressing issues that emerge with the rise of medical tourism; a need for decision aids to improve communication with patients.

Conceptualizing depression in Vietnam: Primary health care providers' explanatory models of depression.

The purpose of this qualitative study was to elicit the explanatory models (EMs) of primary healthcare providers (PHPs) in Vietnam in order to (a) understand if and how the concept of depression is understood in Vietnam from the perspective of nonspecialist providers and community members, and (b) to inform the process of introducing services for depression in primary care in Vietnam. We conducted semistructured interviews with 30 PHPs in one rural and one urban district of Hanoi, Vietnam in 2014. We found that although PHPs possess low levels of formal knowledge about depression, they provide consistent accounts of its symptoms and aetiology among their patient population, suggesting that depression is a relevant concept in Vietnam. PHPs describe a predominantly psychosocial understanding of depression, with little mention of either affective symptoms or neurological aetiology. This implies that, with enhanced training, psychosocial approaches to depression care would be appropriate and acceptable in this context. Distinctions were identified between rural and urban populations in both understandings of depression and help-seeking, suggesting that enhanced services should account for the diversity of the Vietnamese context. Alcohol misuse among men emerged as a considerable concern, both in relation to depression and as stand-alone issue facing Vietnamese communities, indicating the need for further research in this area. Low help-seeking for depression in primary care implies the need for enhanced community outreach. The results of this study demonstrate the value of eliciting EMs to inform planning for enhanced mental health service delivery in a global context.

Appropriate Reconciliation of Cardiovascular Medications After Elective Surgery and Postdischarge Acute Hospital and Ambulatory Visits.

OBJECTIVE: To describe appropriate discharge reconciliation of cardiovascular medications and assess associations with postdischarge healthcare utilization in surgical patients. DESIGN: Retrospective cohort study from January 2007 to December 2011. SETTING: An academic medical center. PATIENTS: Seven hundred and fifty-two adults undergoing elective noncardiac surgery and taking antiplatelet agents, beta-blockers, renin-angiotensin system inhibitors, or statin lipid-lowering agents before surgery. MEASUREMENTS: Primary predictor: appropriate discharge reconciliation of preoperative cardiovascular medications (continuation without documented contraindications). Primary outcomes: acute hospital visits (emergency department visits or hospitalizations) and unplanned ambulatory visits (primary care or surgical) at 30 days after surgery. RESULTS: Preoperative medications were appropriately reconciled in 436 (58.0%) patients. For individual medications, appropriate discharge reconciliation occurred for 156 of the 327 patients on antiplatelet agents (47.7%), 507 of the 624 patients on beta-blockers (81.3%), 259 of the 361 patients on renin-angiotensin system inhibitors (71.8%), and 302 of the 406 patients on statins (74.4%). In multivariable analyses, appropriate reconciliation of all preoperative medications was not associated with acute hospital (adjusted odds ratio [AOR], 0.94; 95% confidence interval [CI], 0.63-1.41) or unplanned ambulatory visits (AOR, 1.48; 95% CI, 0.94-2.35). Appropriate reconciliation of statin therapy was associated with lower odds of acute hospital visits (AOR, 0.47; 95% CI, 0.26-0.85). There were no other statistically significant associations between appropriate reconciliation of individual medications and either outcome. CONCLUSIONS: Although large gaps in appropriate discharge reconciliation of chronic cardiovascular medications were common in patients undergoing elective surgery, these gaps were not consistently associated with postdischarge acute hospital or ambulatory visits.

The Use of Text Messaging to Improve the Hospital-to-Community Transition in Acute Coronary Syndrome Patients (Txt2Prevent): Intervention Development and Pilot Randomized Controlled Trial Protocol.

BACKGROUND: Acute coronary syndrome, including acute myocardial infarction (AMI), is one of the leading causes for hospitalization, with AMI 30-day readmission rates around 20%. Supporting patient information needs and increasing adherence to recommended self-management behaviors during transition from hospital to home has the potential to improve patient outcomes. Text messages have been effective in other interventions and may be suitable to provide support to patients during this transition period. OBJECTIVE: The goal of this study is to pilot test a text messaging intervention program (Txt2Prevent) that supports acute coronary syndrome patients for 60 days postdischarge. The primary objective is to compare self-management, as measured by the Health Education Impact Questionnaire, between patients receiving only usual care versus those who receive usual care plus the Txt2Prevent intervention. The secondary objectives are to compare medication adherence, health-related quality of life, self-efficacy, health care resource use (and associated costs), all-cause and cardiovascular disease (CVD) readmission, and all-cause and CVD mortality rates between the 2 groups. The third objective is to assess acceptability of the text messaging intervention and feasibility of the study protocol. METHODS: This is a randomized controlled trial with blinding of outcome assessors. The Txt2Prevent program includes automated text messages to patients about standard follow-up care, general self-management, and healthy living. The content of the text messages was informed by and developed based on interviews with patients, discharge materials, theoretical domains of behavior, and a clinical advisory group composed of patients, clinicians, and researchers. We will recruit 76 consecutive cardiac in-patients with acute coronary syndrome who are treated with either medical management or percutaneous coronary intervention from a hospital in Vancouver, Canada. RESULTS: Assessments at baseline will include measures for demographic information, self-management, health-related quality of life, and self-efficacy. Assessments at follow-up will include medication adherence, readmissions, health care resource use, and mortality in addition to the reassessment of baseline measures. Baseline assessments are done in-person while follow-up assessments are completed through a combination of mailed packages and phone calls. Semistructured interviews with participants will also be performed to better understand participant experiences managing their condition and with the text messages. CONCLUSIONS: This study will determine preliminary efficacy, feasibility, and acceptability of the Txt2Prevent program to support acute coronary syndrome patients in the transition to home following hospital discharge. The results of this study will be used to inform a larger trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT02336919; https://clinicaltrials.gov/ct2/show/NCT02336919 (Archived by WebCite at http://www.webcitation.org/6qMjEqo6O).

The "minimizing antibiotic resistance in Colorado" project: impact of patient education in improving antibiotic use in private office practices.

OBJECTIVE: To assess the marginal impact of patient education on antibiotic prescribing to children with pharyngitis and adults with acute bronchitis in private office practices. DATA SOURCES/STUDY SETTING: Antibiotic prescription rates based on claims data from four managed care organizations in Colorado during baseline (winter 2000) and study (winter 2001) periods. STUDY DESIGN: A nonrandomized controlled trial of a household and office-based patient educational intervention was performed. During both periods, Colorado physicians were mailed antibiotic prescribing profiles and practices guidelines as part of an ongoing quality improvement program. Intervention practices (n=7) were compared with local and distant control practices. DATA COLLECTION/EXTRACTION METHODS: Office visits were extracted by managed care organizations using International Classification of Diseases-9-Clinical Modification codes for acute respiratory tract infections, and merged with pharmacy claims data based on visit and dispensing dates coinciding within 2 days. PRINCIPAL FINDINGS: Adjusted antibiotic prescription rates during baseline and study periods increased from 38 to 39 percent for pediatric pharyngitis at the distant control practices, and decreased from 39 to 37 percent at the local control practices, and from 34 to 30 percent at the intervention practices (p=.18 compared with distant control practices). Adjusted antibiotic prescription rates decreased from 50 to 44 percent for adult bronchitis at the distant control practices, from 55 to 45 percent at the local control practices, and from 60 to 36 percent at the intervention practices (p<.002 and p=.006 compared with distant and local control practices, respectively). CONCLUSIONS: In office practices, there appears to be little room for improvement in antibiotic prescription rates for children with pharyngitis. In contrast, patient education helps reduce antibiotic use for adults with acute bronchitis beyond that achieved by physician-directed efforts.

Selection of depression measures for use among Vietnamese populations in primary care settings: a scoping review.

Depression is an important and growing contributor to the burden of disease around the world and evidence suggests the experience of depression varies cross-culturally. Efforts to improve the integration of services for depression in primary care are increasing globally, meaning that culturally valid measures that are acceptable for use in primary care settings are needed. We conducted a scoping review of 27 studies that validated or used 10 measures of depression in Vietnamese populations. We reviewed the validity of the instruments as reported in the studies and qualitatively assessed cultural validity and acceptability for use in primary care. We found much variation in the methods used to validate the measures, with an emphasis on criterion validity and reliability. Enhanced evaluation of content and construct validity is needed to ensure validity within diverse cultural contexts such as Vietnam. For effective use in primary care, measures must be further evaluated for their brevity and ease of use. To identify appropriate measures for use in primary care in diverse populations, assessment must balance standard validity testing with enhanced testing for appropriateness in terms of culture, language, and gender and for acceptability for use in primary care.

Antibiotic treatment of acute respiratory tract infections in the elderly: effect of a multidimensional educational intervention.

OBJECTIVES: : To measure and improve antibiotic use for acute respiratory tract infections (ARIs) in the elderly. DESIGN: : Prospective, nonrandomized controlled trial. SETTING: : Ambulatory office practices in Denver metropolitan area (n=4 intervention practices; n=51 control practices). PARTICIPANTS: : Consecutive patients enrolled in a Medicare managed care program who were diagnosed with ARIs during baseline (winter 2000/2001) and intervention (winter 2001/2002) periods. A total of 4,270 patient visits were analyzed (including 341 patient visits in intervention practices). INTERVENTION: : Appropriate antibiotic use and antibiotic resistance educational materials were mailed to intervention practice households. Waiting and examination room posters were provided to intervention office practices. MEASUREMENTS: : Antibiotic prescription rates, based on administrative office visit and pharmacy data, for total and condition-specific ARIs. RESULTS: : There was wide variation in antibiotic prescription rates for ARIs across unique practices, ranging from 21% to 88% (median=54%). Antibiotic prescription rates varied little by patient age, sex, and underlying chronic lung disease. Prescription rates varied by diagnosis: sinusitis (69%), bronchitis (59%), pharyngitis (50%), and nonspecific upper respiratory tract infection (26%). The educational intervention was not associated with greater reduction in antibiotic prescription rates for total or condition-specific ARIs beyond a modest secular trend (P=.79). CONCLUSION: : Wide variation in antibiotic prescription rates suggests that quality improvement efforts are needed to optimize antibiotic use in the elderly. In the setting of an ongoing physician intervention, a patient education intervention had little effect. Factors other than patient expectations and demands may play a stronger role in antibiotic treatment decisions in elderly populations.

Targeting of chemoprevention to high-risk potentially malignant oral lesions: challenges and opportunities.

Worldwide, oral cancer is responsible for 170,000 deaths per year. Intervention to prevent this disease is a long sought after goal. Chemoprevention studies have focused on clinicopathological features of potentially malignant lesions (PML) in an effort to prevent their progression to cancer. However, prediction of future behavior for such lesions is difficult and remains a major challenge to such intervention. Different approaches to this problem have been tested in the past 20years. Early genetic progression models identified critical regions of allelic imbalance at 3p and 9p, and provided the basis for molecular markers to identify progressing PMLs. Subsequently, technological advances, such as genome-wide high-throughput array platforms, computer imaging, visualization technology and next generation sequencing, have broadened the scope for marker development and have the potential of further improving our ability to identify high-risk lesions in the near future either alone or in combination. In this article, we examine the milestones in the development of markers for PML progression. We emphasize the critical importance of networks among scientists, health professionals and community to facilitate the validation and application of putative markers into clinical practice. With a growing number of new agents to validate, it is necessary to coordinate the design and implementation of strategies for patient recruitment, integration of marker assessment, and the final translation of such approaches into clinical use.

"We are not being heard": Aboriginal perspectives on traditional foods access and food security.

Aboriginal peoples are among the most food insecure groups in Canada, yet their perspectives and knowledge are often sidelined in mainstream food security debates. In order to create food security for all, Aboriginal perspectives must be included in food security research and discourse. This project demonstrates a process in which Aboriginal and non-Aboriginal partners engaged in a culturally appropriate and respectful collaboration, assessing the challenges and barriers to traditional foods access in the urban environment of Vancouver, BC, Canada. The findings highlight local, national, and international actions required to increase access to traditional foods as a means of achieving food security for all people. The paper underscores the interconnectedness of local and global food security issues and highlights challenges as well as solutions with potential to improve food security of both Aboriginal and non-Aboriginal peoples alike.

"Get smart Colorado": impact of a mass media campaign to improve community antibiotic use.

CONTEXT: Large-scale strategies are needed to reduce overuse of antibiotics in US communities. OBJECTIVES: To evaluate the impact of a mass media campaign-"Get Smart Colorado"-on public exposure to campaign, antibiotic use, and office visit rates. DESIGN: Nonrandomized controlled trial. SETTING: Two metropolitan communities in Colorado, United States. SUBJECTS: The general public, managed care enrollees, and physicians residing in the mass media (2.2 million persons) and comparison (0.53 million persons) communities. INTERVENTION: : The campaign consisting of paid outdoor advertising, earned media and physician advocacy ran between November 2002 and February 2003. PRINCIPAL MEASURES: Antibiotics dispensed per 1000 persons or managed care enrollees, and the proportion of office visits receiving antibiotics measured during 10 to 12 months before and after the campaign. RESULTS: After the mass media campaign, there was a 3.8% net decrease in retail pharmacy antibiotic dispenses per 1000 persons (P = 0.30) and an 8.8% net decrease in managed care-associated antibiotic dispenses per 1000 members (P = 0.03) in the mass media community. Most of the decline occurred among pediatric members, and corresponded with a decline in pediatric office visit rates. There was no change in the office visit prescription rates among pediatric or adult managed care members, nor in visit rates for complications of acute respiratory tract infections. CONCLUSIONS: A low-cost mass media campaign was associated with a reduction in antibiotic use in the community, and seems to be mediated through decreases in office visits rates among children. The campaign seems to be cost-saving.