Weighting of Criteria for Disease Prioritization Using Conjoint Analysis and Based on Health Professional and Student Opinion

Disease prioritization exercises have been used by several organizations to inform surveillance and control measures. Though most methodologies for disease prioritization are based on expert opinion, it is becoming more common to include different stakeholders in the prioritization exercise. This study was performed to compare the weighting of disease criteria, and the consequent prioritization of zoonoses, by both health professionals and students in Switzerland using a Conjoint Analysis questionnaire. The health professionals comprised public health and food safety experts, cantonal physicians and cantonal veterinarians, while the student group comprised first-year veterinary and agronomy students. Eight criteria were selected for this prioritization based on expert elicitation and literature review. These criteria, described on a 3-tiered scale, were evaluated through a choice-based Conjoint Analysis questionnaire with 25 choice tasks. Questionnaire results were analyzed to obtain importance scores (for each criterion) and mean utility values (for each criterion level), and the latter were then used to rank 16 zoonoses. While the most important criterion for both groups was “Severity of the disease in humans”, the second ranked criteria by the health professionals and students were “Economy” and “Treatment in humans”, respectively. Regarding the criterion “Control and Prevention”, health professionals tended to prioritize a disease when the control and preventive measures were described to be 95% effective, while students prioritized a disease if there were almost no control and preventive measures available. Bovine Spongiform Encephalopathy was the top-ranked disease by both groups. Health professionals and students agreed on the weighting of certain criteria such as “Severity” and “Treatment of disease in humans”, but disagreed on others such as “Economy” or “Control and Prevention”. Nonetheless, the overall disease ranking lists were similar, and these may be taken into consideration when making future decisions regarding resource allocation for disease control and prevention in Switzerland.     

Attenuation of Typical Sex Differences in 800 Adults with Autism vs. 3,900 Controls

Sex differences have been reported in autistic traits and systemizing (male advantage), and empathizing (female advantage) among typically developing individuals. In individuals with autism, these cognitive-behavioural profiles correspond to predictions from the “extreme male brain” (EMB) theory of autism (extreme scores on autistic traits and systemizing, below average on empathizing). Sex differences within autism, however, have been under-investigated. Here we show in 811 adults (454 females) with autism and 3,906 age-matched typical control adults (2,562 females) who completed the Empathy Quotient (EQ), the Systemizing Quotient-Revised (SQ-R), and the Autism Spectrum Quotient (AQ), that typical females on average scored higher on the EQ, typical males scored higher on the SQ-R and AQ, and both males and females with autism showed a shift toward the extreme of the “male profile” on these measures and in the distribution of “brain types” (the discrepancy between standardized EQ and SQ-R scores). Further, normative sex differences are attenuated but not abolished in adults with autism. The findings provide strong support for the EMB theory of autism, and highlight differences between males and females with autism.     

Is the Excessive Use of Microblogs an Internet Addiction? Developing a Scale for Assessing the Excessive Use of Microblogs in Chinese College Students

More and more college students are using microblogs, with some excessive users demonstrating addiction-like symptoms. However, there is currently no published scale available for use in assessing excessive use of these microblogs, a significant impediment to advancing this area of research. We collected data from 3,047 college students in China and developed a Microblog Excessive Use Scale (MEUS) for Chinese college students, comparing it with criteria used for assessing Internet addiction. Our diagnostic scale featured three factors, two of which–“withdrawal and health problem” and “time management and performance”–are already included in Internet addiction assessment scales. The third factor, “social comfort,” does not appear in Internet addiction assessment scales. Our study found that females have significantly higher MEUS scores than males, and that total MEUS scores positively correlated with scores from “self-disclosure” and “real social interaction” scales. These findings differ from results obtained in previous investigations into Internet addiction. Our results indicate that some characteristics of the excessive use of microblogs are different to those of Internet addiction, suggesting that microblog overuse may not correspond exactly to the state of Internet addiction.     

1590名农村中老年人生存质量调查分析(英文)

目的:采用SF-36量表中文版评价农村中老年人生存质量,并为提高农村中老年人的生存质量和健康水平提供科学依据和建议。方法:采用随机抽样的方法,采用面对面访谈的形式,记分方法参照国际生存质量评价计划(IQOLA)的制定标准,评价其生理和心理健康状况。结果:1590名农村中老年人男性生存质量得分高于女性。经济水平对农村中老年人的生理健康的影响大于对其心理健康的影响。配偶健在的农村中老年人的各维度得分均高于无配偶者。农村中老年人的各维度得分随教育水平的升高呈升高趋势。结论:农村中老年人的生存质量与年龄成负相关,同时也受文化程度和经济水平等多个因素的影响。因而,对农村中老年人这一弱势群体应该给予更多关注。     

Prevalence and tracking of weight disorders in Italian primary school students: a three-year follow-up

Obesity has been widely described as the latest epidemic, and in some areas obesity co-exists with undernutrition. The purpose of this study was to assess the variability of weight status of a cohort of 279 Italian primary school students followed longitudinally for three years. Overweight was the most common weight status disorder in both sexes and generally prevailed in females. Underweight was also more frequent in females than males, while males generally showed a higher incidence of obesity. Overweight showed the highest stability in females. In males, tracking of overweight was 62.5%, while that of normal weight was 89.36%. Overweight tracks through the three consecutive years in a high percentage of both sexes. In the whole sample (regardless of sex and weight category), overweight shows the highest increase over the three-year period. This study provides public health professionals with useful data for policy planning in regard to childhood obesity.     

“Cancer – Educate to Prevent” – High-School Teachers,the New Promoters of Cancer Prevention Education Campaigns

Cancer is one of the leading causes of death worldwide, and thus represents a priority for national public health programs. Prevention has been assumed as the best strategy to reduce cancer burden, however most cancer prevention programs are implemented by healthcare professionals, which constrain range and educational impacts.We developed an innovative approach for cancer prevention education focused on high-school biology teachers, considered privileged mediators in the socialization processes. A training program, “Cancer, Educate to Prevent” was applied, so that the teachers were able to independently develop and implement prevention campaigns focused on students and school-related communities. The program encompassed different educational modules, ranging from cancer biology to prevention campaigns design. Fifty-four teachers were empowered to develop and implement their own cancer prevention campaigns in a population up to five thousands students.The success of the training program was assessed through quantitative evaluation – questionnaires focused on teachers'' cancer knowledge and perceptions, before the intervention (pre-test) and immediately after (post-test). The projects developed and implemented by teachers were also evaluated regarding the intervention design, educational contents and impact on the students'' knowledge about cancer. This study presents and discusses the results concerning the training program “Cancer, Educate to Prevent” and clearly shows a significant increase in teacher''s cancer literacy (knowledge and perceptions) and teachers'' acquired proficiency to develop and deliver cancer prevention campaigns with direct impact on students'' knowledge about cancer.This pilot study reinforces the potential of high-school teachers and schools as cancer prevention promoters and opens a new perspective for the development and validation of cancer prevention education strategies, based upon focused interventions in restricted targets (students) through non-health professionals (teachers).     

Challenges and Opportunities: What Can We Learn from Patients Living with Chronic Musculoskeletal Conditions,Health Professionals and Carers about the Concept of Health Literacy Using Qualitative Methods of Inquiry?

The field of health literacy continues to evolve and concern public health researchers and yet remains a largely overlooked concept elsewhere in the healthcare system. We conducted focus group discussions in England UK, about the concept of health literacy with older patients with chronic musculoskeletal conditions (mean age  = 73.4 years), carers and health professionals. Our research posed methodological, intellectual and practical challenges. Gaps in conceptualisation and expectations were revealed, reiterating deficiencies in predominant models for understanding health literacy and methodological shortcomings of using focus groups in qualitative research for this topic. Building on this unique insight into what the concept of health literacy meant to participants, we present analysis of our findings on factors perceived to foster and inhibit health literacy and on the issue of responsibility in health literacy. Patients saw health literacy as a result of an inconsistent interactive process and the implications as wide ranging; healthcare professionals had more heterogeneous views. All focus group discussants agreed that health literacy most benefited from good inter-personal communication and partnership. By proposing a needs-based approach to health literacy we offer an alternative way of conceptualising health literacy to help improve the health of older people with chronic conditions.     

Patients’ attitudes to the summary care record and HealthSpace: qualitative study

Objective To document the views of patients and the public towards the summary care record (SCR, a centrally stored medical record drawn from the general practice record) and HealthSpace (a personal health organiser accessible through the internet from which people can view their SCR), with a particular focus on those with low health literacy, potentially stigmatising conditions, or difficulties accessing health care.Design 103 semistructured individual interviews and seven focus groups.Setting Three early adopter primary care trusts in England where the SCR and HealthSpace are being piloted. All were in areas of relative socioeconomic deprivation.Participants Individual participants were recruited from general practice surgeries, walk-in centres, out of hours centres, and accident and emergency departments. Participants in focus groups were recruited through voluntary sector organisations; they comprised advocates of vulnerable groups and advocates of people who speak limited English; people with HIV; users of mental health services; young adults; elderly people; and participants of a drug rehabilitation programme.Methods Participants were asked if they had received information about the SCR and HealthSpace and about their views on shared electronic records in different circumstances.Results Most people were not aware of the SCR or HealthSpace and did not recall receiving information about it. They saw both benefits and drawbacks to having an SCR and described a process of weighing the former against the latter when making their personal choice. Key factors influencing this choice included the nature of any illness (especially whether it was likely to lead to emergency care needs); past and present experience of healthcare and government surveillance; the person’s level of engagement and health literacy; and their trust and confidence in the primary healthcare team and the wider NHS. Overall, people with stigmatising illness were more positive about the SCR than people who claimed to speak for “vulnerable groups.” Misconceptions about the SCR were common, especially confusion about what data it contained and who would have access to it. Most people were not interested in recording their medical data or accessing their SCR via HealthSpace, but some saw the potential for this new technology to support self management and lay care for those with chronic illness.Conclusion Despite an extensive information programme in early adopter sites, the public remains unclear about current policy on shared electronic records, though most people view these as a positive development. The “implied consent” model for creating and accessing a person’s SCR should be revisited, perhaps in favour of “consent to view” at the point of access.     

Age-Dependent Sex Difference of the Incidence and Mortality of Status Epilepticus: A Twelve Year Nationwide Population-Based Cohort Study in Taiwan

Status epilepticus (SE) is a serious neurologic emergency associated with a significant mortality. The objective of this study is to investigate its epidemiology in terms of age- and sex-specific incidences and mortality. By using the Taiwan National Health Insurance Research Database during 2000 to 2011, we identified hospitalized patients with a discharged diagnosis of SE and calculated the incidence and in-hospital mortality of SE with respect to age and sex. The overall incidence of SE was 4.61 per 100,000 person-years, which displayed a “J-shaped” distribution by age with a little higher under the age of 5 and highest over 60 years. The male-to-female rate ratio was 1.57 and it demonstrated a “mountain-shape” across ages with the peak at 45 to 49 years old. The in-hospital mortality was significantly lower in males (7.38%) than in females (11.12%) with an odds ratio of 0.64 (95% CI 0.56-0.72). Notably, the in-hospital mortality for females increased rapidly after the age of 40 to 45 years. The multivariate analysis found males had a significantly lower risk of mortality than females after, but not before, 45 years of age with an odds ratio of 0.56 (95% CI 0.49-0.65). Sex and age are crucial factors associated with the incidence and in-hospital mortality of SE. The females over 45 years of age have a higher risk of occurrence and mortality from SE. The underlying mechanism deserves further study.     

Patient Satisfaction with Methadone Maintenance Treatment in Vietnam: A Comparison of Different Integrative-Service Delivery Models

Background

Patient satisfaction is an important component of quality in healthcare delivery. To inform the expansion of Methadone Maintenance Treatment (MMT) services in Vietnam, we examined the satisfaction of patients with regards to different services delivery models and identified its associated factors.

Methods

We interviewed 1,016 MMT patients at 5 clinics in Hanoi and Nam Dinh province. The modified SATIS instrument, a 10-item scale, was used to measure three dimensions: “Services quality and convenience”, “Health workers’ capacity and responsiveness” and “Inter-professional care”.

Results

The average score was high across three SATIS dimensions. However, only one third of patients completely satisfied with general health services and treatment outcomes. Older age, higher education, having any problem in self-care and anxiety/depression were negatively associated with patient’s satisfaction. Meanwhile, patients receiving MMT at clinics, where more comprehensive HIV and general health care services were available, were more likely to report a complete satisfaction.

Conclusion

Patients were highly satisfied with MMT services in Vietnam. However, treatment for drug users should go beyond methadone maintenance to address complicated health demands of drug users. Integrating MMT with comprehensive HIV and general health services together with improving the capacity of health workers and efficiency of services organisation to provide interconnected health care for drug users are critical for improving the outcomes of the MMT program.     

The Concordance of Care for Age Related Macular Degeneration with the Chronic Care Model: A Multi-Centered Cross-Sectional Study

Aims

The aim of the study was to assess the concordance of care for age related macular degeneration with the evidence-based framework for care for chronic medical conditions known as the chronic care model. Furthermore we aimed to identify factors associated with the concordance of care with the chronic care model.

Methods

Multi-centered cross-sectional study. 169 patients beginning medical treatment for age related macular degeneration were recruited and analyzed. Patients completed the Patient Assessment of Chronic Illness Care (PACIC) questionnaire, reflecting accordance to the chronic care model from a patient’s perspective, the National Eye Institute Visual Functioning Questionnaire-25 (NEI-VFQ-25) and Patient Health Questionnaire (PHQ-9). Visual acuity and chronic medical conditions were assessed. Nonparametric tests and correlation analyses were performed, also multivariable regression analysis.

Results

The median PACIC summary score was 2.4 (interquartile range 1.75 to 3.25), the lowest PACIC subscale score was “follow-up/coordination” with a median of 1.8 (interquartile range 1.00 to 2.60). In multivariable regression analysis the presence of diabetes type 2 was strongly associated with low PACIC scores (coefficient = −0.85, p = 0.007).

Conclusion

Generally, care for patients with age related macular degeneration by ophthalmologists is in moderate concordance with the chronic care model. Concerning follow-up and coordination of health service, large improvements are possible. Future research should answer the question how healthcare delivery can be improved effecting relevant benefits to patients with AMD.     

What can experience add to early medical education? Consensus survey

Objective To provide a rationale for integrating experience into early medical education (“early experience”).Design Small group discussions to obtain stakeholders'' views. Grounded theory analysis with respondent, internal, and external validation.Setting Problem based, undergraduate medical curriculum that is not vertically integrated.Participants A purposive sample of 64 students, staff, and curriculum leaders from three university medical schools in the United Kingdom.Results Without early experience, the curriculum was socially isolating and divorced from clinical practice. The abruptness of students'' transition to the clinical environment in year 3 generated positive and negative emotions. The rationale for early experience would be to ease the transition; orientate the curriculum towards the social context of practice; make students more confident to approach patients; motivate them; increase their awareness of themselves and others; strengthen, deepen, and contextualise their theoretical knowledge; teach intellectual skills; strengthen learning of behavioural and social sciences; and teach them about the role of health professionals.Conclusion A rationale for early experience would be to strengthen and deepen cognitively, broaden affectively, contextualise, and integrate medical education. This is partly a process of professional socialisation that should start earlier to avoid an abrupt transition. “Experience” can be defined as “authentic human contact in a social or clinical context that enhances learning of health, illness or disease, and the role of the health professional.”     

Movement Discordance between Healthy and Non-Healthy US Adults

Introduction

Physical activity is known to significantly impact cardiometabolic health. Accelerometer data, as a measure of physical activity, can be used to objectively identify a disparity in movement (movement discordance) between healthy and unhealthy adults. The purpose of this study was to examine the Movement Discordance between healthy and unhealthy adults in a large US population sample.

Methods

Demographic, health and accelerometer data from the National Health and Nutrition Examination Study (NHANES) 2003–2004 and 2005–2006 cohorts were used for this study. Participants were classified as either having a “normal” or “abnormal” value for each cardiometabolic health parameter examined, based on published criteria. Linear regression analyses were performed to determine significance of each abnormal health parameter (risk factor) in its unique effect on the accelerometer counts, controlling for age and gender. Average accelerometer counts per minute (cpm) by gender and age categories were estimated separately for the groups of normal and abnormal cardiometabolic risk.

Results

Average cpm for those with healthy levels of each individual cardiometabolic health parameter range from 296 cpm (for C reactive protein) to 337 cpm (for waist circumference), while average cpm for those with abnormal levels of each individual cardiometabolic health parameter range from 216 cpm (for insulin) to 291 cpm (for LDL-cholesterol). After controlling for age and gender, waist circumference, HbA1c, Insulin, Homocysteine, and HDL-Cholesterol were the cardiometabolic health parameters that showed significant, unique and independent effects on cpm. Overall, individuals who have abnormal values for all significant cardiometabolic health parameters (“unhealthy”) averaged 267 cpm (SE = 15 cpm), while the healthy sample of this study averaged 428 cpm (SE = 10 cpm). The difference in cpm between the unhealthy and healthy groups is similar between males and females. Further, for both males and females, the cpm gap between unhealthy and healthy is largest in the 30s (males: 183 cpm; females 144 cpm) and lessens as age increases, with the lowest gap seen in those 80+ years (males, 81 cpm; females, 85 cpm).

Conclusion

This Movement Discordance between healthy and unhealthy adults represents a gap in movement that needs to be closed to improve the health of individuals with, or at risk for cardiometabolic disease.     

The Selection of Medical Students in Western Canada

The methods employed in the selection of medical students for the 1964-65 class of freshmen at the four Western medical schools are described and recommendations are made for improving the procedure. The structure and functions of the various selection committees varied from school to school but their prime purpose was the same—the selection of “good students” who would later become “good physicians”. Not surprisingly, academic achievement and confidence in estimating this ranked highest in importance, and while non-intellectual characteristics ranked almost as high, committee members had no confidence that they could evaluate these qualities.It is suggested that the ideal selection committee would be a “high-priority” committee consisting of six to eight members who would meet at least twice a year, have tenure of at least four years, be trained in interviewing applicants, consider Medical College Admission Test scores, review applications before each meeting, and establish research committees to investigate the students they choose.     

Medical Students’ Attitudes towards Overweight and Obesity

Objective

Studies from the USA have identified medical students as a major source of stigmatizing attitudes towards overweight and obese individuals. As data from Europe is scarce, medical students’ attitudes were investigated at the University of Leipzig in Leipzig, Germany.

Design

Cross-sectional survey containing an experimental manipulation consisting of a pair of vignettes depicting an obese and a normal weight 42-year-old woman, respectively. Vignettes were followed by the Fat Phobia Scale (FPS), a semantic differential assessing weight related attitudes. In case of the overweight vignette a panel of questions on causal attribution for the overweight preceded administration of the FPS.

Subjects

671 medical students were enrolled at the University of Leipzig from May to June 2011.

Results

The overweight vignette was rated significantly more negative than the normal weight vignette (mean FPS score 3.65±0.45 versus 2.54±0.38, p<0.001). A higher proportion of students had negative attitudes towards the overweight as compared to the normal weight individual (98.9% versus 53.7%, p<0.001). A “positive energy balance” was perceived as the most relevant cause for the overweight, followed by “negligent personality trait”, “societal and social environment” and “biomedical causes”. Attributing a “positive energy balance” or “negligent personality trait” as relevant cause for the overweight was positively associated with negative attitudes.

Conclusion

The results of this study confirm and complement findings from other countries, mainly the USA, and indicate that weight bias in the health care setting may be a global issue. Stigmatizing attitudes towards overweight and obesity are prevalent among a sample of medical students at the University of Leipzig. Negative attitudes arise on the basis of holding the individual accountable for the excess weight. They call for bringing the topic of overweight and obesity more into the focus of the medical curriculum and for enhancing medical students’ awareness of the complex aetiology of this health condition.     

Introducing Indonesian Medical Students to Rainforest Conservation and Community Health in the Field: A Practicum Experience in East Kalimantan

This article describes a practicum experience developed between a conservation organization (The Nature Conservancy) and a medical school (The Faculty of Medicine at Mulawarman University in East Kalimantan). Through this practicum, groups of medical students from Mulawarman have assisted with baseline and follow-up community evaluations in remote villages along the Kelay River, Berau District. These evaluations were done in conjunction with the Kelay Conservation Health Program, a program designed to improve health and healthcare for local people, mostly former hunter–gatherers, in an area of rainforest that the conservation organization seeks to protect. Besides gaining experience in community health assessment, through this practicum medical students also gained field experience and knowledge in rural and remote area health and healthcare in Indonesia and had an opportunity to explore linkages between conservation and health. At the conclusion of their time with the program, participating students also presented individual problem-based reports on relevant topics to students and faculty at the Medical School and to the District Health Department. This partnership between a conservation agency and a medical school in a developing country is unusual, but has been very well received by all stakeholders involved. Because of this, Mulawarman is now planning to make Kelay into a formal training site for its students. This experience may serve as a model for other groups interested in promoting ecosystem health education to future health professionals in the developing world.     

The Epidemiology of Alcohol Use and Alcohol Use Disorders among Young People in Northern Tanzania

IntroductionAlcohol use is a global public health problem, including as a risk factor for HIV infection, but few data are available on the epidemiology of alcohol use and alcohol use disorders (AUD) among young people in sub-Saharan Africa.MethodsWe conducted a cross-sectional survey among 4 groups of young people aged 15–24 years old (secondary school students, college/university students, employees of local industries and casual labourers) in two regions (Kilimanjaro and Mwanza) of northern Tanzania. Using a multistage stratified random sampling strategy, we collected information on demographics, alcohol use, and behavioural factors. We screened severity of alcohol use using the Alcohol Use Disorder Identification Test (AUDIT) and estimated the quantity and frequency of alcohol consumption using the timeline-follow-back-calendar (TLFB) method.ResultsA total of 1954 young people were surveyed. The prevalence of reported alcohol use was higher among males (47–70% ever users and 20–45% current users) than females (24–54% ever users and 12–47% current users). Prevalence of use was substantially higher in Kilimanjaro than Mwanza region. In both regions, participants reported high exposure to alcohol advertisements, and wide alcohol availability. College students reported the highest prevalence of current alcohol use (45% among males; 26% among females) and of heavy episodic drinking (71% among males; 27% among females) followed by casual labourers. Males were more likely to have AUD (an AUDIT score ≥8) than females, with 11–28% of males screening positive for AUD. Alcohol use was associated with male gender, being in a relationship, greater disposable income, non-Muslim religion and a higher number of sexual partners.ConclusionsAlcohol use is a significant problem among young people in northern Tanzania. There is an urgent need to develop, pilot and deliver interventions to help young people delay initiation and reduce levels of harmful drinking, particularly among college students and casual labourers.     

Validity and Reliability of the Japanese Version of the Newest Vital Sign: A Preliminary Study

Health literacy (HL) refers to the ability to obtain, process, and understand basic health information and services, and is thus needed to make appropriate health decisions. The Newest Vital Sign (NVS) is comprised of 6 questions about an ice cream nutrition label and assesses HL numeracy skills. We developed a Japanese version of the NVS (NVS-J) and evaluated the validity and reliability of the NVS-J in patients with chronic pain. The translation of the original NVS into Japanese was achieved as per the published guidelines. An observational study was subsequently performed to evaluate the validity and reliability of the NVS-J in 43 Japanese patients suffering from chronic pain. Factor analysis with promax rotation, using the Kaiser criterion (eigenvalues ≥1.0), and a scree plot revealed that the main component of the NVS-J consists of three determinative factors, and each factor consists of two NVS-J items. The criterion-related validity of the total NVS-J score was significantly correlated with the total score of Ishikawa et al.''s self-rated HL Questionnaire, the clinical global assessment of comprehensive HL level, cognitive function, and the Brinkman index. In addition, Cronbach''s coefficient for the total score of the NVS-J was adequate (alpha = 0.72). This study demonstrated that the NVS-J has good validity and reliability. Further, the NVS-J consists of three determinative factors: “basic numeracy ability,” “complex numeracy ability,” and “serious-minded ability.” These three HL abilities comprise a 3-step hierarchical structure. Adequate HL should be promoted in chronic pain patients to enable coping, improve functioning, and increase activities of daily living (ADLs) and quality of life (QOL).     

Task Shifting for Non-Communicable Disease Management in Low and Middle Income Countries – A Systematic Review

Background

One potential solution to limited healthcare access in low and middle income countries (LMIC) is task-shifting- the training of non-physician healthcare workers (NPHWs) to perform tasks traditionally undertaken by physicians. The aim of this paper is to conduct a systematic review of studies involving task-shifting for the management of non-communicable disease (NCD) in LMIC.

Methods

A search strategy with the following terms “task-shifting”, “non-physician healthcare workers”, “community healthcare worker”, “hypertension”, “diabetes”, “cardiovascular disease”, “mental health”, “depression”, “chronic obstructive pulmonary disease”, “respiratory disease”, “cancer” was conducted using Medline via Pubmed and the Cochrane library. Two reviewers independently reviewed the databases and extracted the data.

Findings

Our search generated 7176 articles of which 22 were included in the review. Seven studies were randomised controlled trials and 15 were observational studies. Tasks performed by NPHWs included screening for NCDs and providing primary health care. The majority of studies showed improved health outcomes when compared with usual healthcare, including reductions in blood pressure, increased uptake of medications and lower depression scores. Factors such as training of NPHWs, provision of algorithms and protocols for screening, treatment and drug titration were the main enablers of the task-shifting intervention. The main barriers identified were restrictions on prescribing medications and availability of medicines. Only two studies described cost-effective analyses, both of which demonstrated that task-shifting was cost-effective.

Conclusions

Task-shifting from physicians to NPHWs, if accompanied by health system re-structuring is a potentially effective and affordable strategy for improving access to healthcare for NCDs. Since the majority of study designs reviewed were of inadequate quality, future research methods should include robust evaluations of such strategies.     

Immunization for Children—Motivating Families to Complete a Series

A communication gap in transmission of information from health professionals to indigent parents is demonstrated by the incomplete immunization of children attending pediatric health facilities. To bridge this gap, young women of similar ethnic and social backgrounds were recruited and trained briefly in counseling parents concerning adequate immunization.The effectiveness of these Health Aides in motivating parents to complete an immunization series was less than that of Public Health Nurses. Even so, the Aides were able to motivate two-thirds of the families that they counseled.Conclusions were that a significant number of children appearing in a large public emergency room facility are unimmunized. Many of these children are not seriously ill and an immunization series can be initiated “on the spot.” Motivation to complete the series can be done almost as satisfactorily by young rapidly trained indigenous Health Aides as by professionals.