Oportunidades -an incentive-based poverty alleviation program- on vaccination coverage for poor and rural older people in Mexico.Immunization is one of the most effective ways of preventing illness, disability and death from infectious diseases for older people. However, worldwide immunization rates are still low, particularly for the most vulnerable groups within the elderly population. The objective of this study was to estimate the effect of the 2007 Oportunidades Evaluation Survey, conducted in low-income households from 741 rural communities  of 13 Mexican states. Vaccination coverage was defined according to three individual vaccines: tetanus, influenza and pneumococcal, and for complete vaccination schedule. Propensity score matching and linear probability model were used in order to estimate the Oportunidades effect.Cross-sectional study, based on Oportunidades and non-Oportunidades populations were 46% and 41% for influenza, 52% and 45% for pneumococcal disease, and 79% and 71% for tetanus, respectively. Oportunidades effect was significant in increasing the proportion of older people vaccinated: for complete schedule 5.5% (CI95% 2.8-8.3), for influenza 6.9% (CI95% 3.8-9.6), for pneumococcal 7.2% (CI95% 4.3-10.2), and for tetanus 6.6% (CI95% 4.1-9.2).12,146 older people were interviewed, and 7% presented cognitive impairment. Among remaining, 4,628 were matched. Low coverage rates were observed for the vaccines analyzed. For Oportunidades increased vaccination rates in the population of older people. There is a need to continue raising vaccination rates, however, particularly for the most vulnerable older people.The results of this study extend the evidence on the effect that conditional transfer programs exert on health indicators. In particular,  The current concept of immunization for older people (OP) can be traced back to at least 40 years, when the first influenza vaccination was recommended . HoweverDespite its limited number of cases, tetanus continues to be one of the leading causes of various health problems among OP. In 2008, there were 122 cases reported in Mexico of tetanus-diphtheria. From these, 23% pertained to this group with a case-fatality rate of approximately 51% [Influenza is a major communicable disease among OP, particularly among those with chronic respiratory and cardiac conditions. During 2008, older adults aged 65 years and above accounted for 16% of hospitalizations and 63% of the deaths attributable to influenza- and pneumococcal-associated infections in Mexico, from a total of 129,282 hospitalizations reported that year [Pneumococcal pneumonia among OP is two times more frequent than the overall incidence of pneumococcal pneumonia in Mexico . AdditioGiven that many of these diseases are preventable by effective vaccination, high infectious disease burdens and consequent morbidity and mortality among the OP is unwarranted. In fact, many studies have demonstrated that immunization is one of the most effective ways of preventing illness, disability and death from infectious diseases -16. The Progresa, Oportunidades began in 1997 as a national CCT program intended to reduce extreme poverty in Mexico, and now is one of the largest CCT programs in the world. The government initially targeted rural areas and then extended the Program to urban areas. Currently, Oportunidades has enrolled nearly five million families in all 32 states nationwide.Conditional cash transfer (CCT) programs are one of the most promising approaches to reducing extreme poverty -22. OrigOportunidades provides cash transfers to poor families contingent on their adherence to activities determined by the program, such as: a) school enrolment of children age 6–16; b) attendance by an adult at a monthly health seminar and, c) compliance by all family members to schedule preventive health check-ups. These preventive medical checkups are expected to promote health and welfare to its beneficiaries. This means that each and every one of the residents of the beneficiary household must comply with doctor visits. Depending on the age of the home dweller, these visits are programmed differently. For older adults, these visits should be carried out once every six months. To ensure the compliance of beneficiary households, medical service providers verify the completion of the required health care visits.Oportunidades selects households that receive the benefits of the program is described in detail in the literature [The process by which terature , so we wOportunidades headquarters in Mexico City and entailed three stages. First, all localities in the country were ranked using a “marginality index” constructed from 1990 National Census data; this index was stratified into five categories and localities in the bottom categories  are pre-selected to be part of the program. Out of 200,151 localities in Mexico, 76,098 rural localities (14.8 million people) were identified in 1997 as having high or very high marginality levels and thus pre-selected for the program.Targeting of poor households was implemented centrally at the In the second stage the program identified poor households within the targeted localities. A community census was administered to all households in the selected localities to retrieve information about household characteristics that determine poverty status, including household income, which is used to identify households below the official poverty line. Predicted poverty status was then computed using the results from a discriminant analysis of the poverty indicator that selects the household characteristics that best discriminate between poor and non-poor households. In general, the best predicting variables were a dependency index (number of children to number of working age adults), an overcrowding index (persons per bedroom), the sex, age and schooling of the household head, the number of children, dwelling characteristics such as dirt floor, bathroom with running water, and access to electricity; and possession of durable goods such as a gas stove, a refrigerator, a washing machine and a vehicle. These characteristics were used to compute the discriminant score that separated eligible and non-eligible households in the selected localities.In stage three, the list of potential beneficiaries of the program was presented to a community assembly where the composition of the list was reviewed; if the assembly rejected a household in the list or an omitted household was alleged to be poor, an administrative process was implemented and the central office delivered a final decision .Oportunidades provides for free the Basic Package of Health Services . This package is designed to meet the health needs of each population group . For older people, the package includes the following services: health promotion, nutrition, prevention and control of diseases, sexual and reproductive health, and vaccination schedule. For the present evaluation, our main reference for proper procedures regarding the provision of health services to OP was derived from the Oportunidades Program Rules of Operation published in 2007 [Once households have been selected -and with the purpose to promote health and welfare of its beneficiaries-  in 2007  which is in 2007 . Both foOportunidades on the vaccination coverage for poor and rural OP in Mexico. Our central hypothesis was that the effect of Oportunidades on EP vaccination coverage could reside in the preventive checkups that the program has made mandatory for program eligibility.Based on information from the OP vaccination schedule provided by the program, the objective of this study was to estimate the effect of Oportunidades program has been conducting evaluation surveys since it was established in 1997. After ten years of formal evaluation in rural areas of Mexico, the program carried out the survey Encuesta de Evaluación de los Hogares Rurales 2007 (ENCEL-2007), including, for the first time, a specific module for collecting data on the sociodemographic characteristics, the health status and the living conditions of OP beneficiaries in Mexico. Within this survey, the term older people referred to individuals aged 65 years and over. Information was also gathered on their household demographic, social and economic characteristics. Both datasets  served to analyze the effect of Oportunidades on OP vaccination coverage as described in more detail later in the statistical analysis section.As part of its monitoring and evaluation efforts, the Instituto Nacional de Salud Pública, INSP) of Mexico using standardized survey materials. Interviewers, who were neither detailed on the study’s objectives or hypotheses nor given any questions on program participation, assumed that the study was aimed at evaluating the overall living conditions of OP. All households in the communities visited were surveyed, and those with at least one resident aged 65 years and above were included in the study. Every OP dwelling in these households were interviewed. We used an adapted version of Folstein’s Mini-Mental State test [Data was collected through household interviews conducted by trained personnel from the National Institute of Public Health  to the nearest health unit. Both were incorporated into the statistical models to estimate the effect of Oportunidades on OP vaccination coverage. Lastly, socio-economic community development data was obtained from a widely used index in Mexico: the marginalization index, which was designed and rendered operational by the National Population Council [On reviewing literature -32 in se Council .Oportunidades evaluation design, the study relied on cross-sectional information, with consequent limitations in its capacity to assess the program’s causal effects. However, it was possible to estimate the effect of the program on the basis of information from Oportunidades beneficiary and non-beneficiary households. With ENCEL-2007 having been implemented throughout the households of the communities visited, it was possible to identify which OP belonged to beneficiary households and which OP did not within the same communities. Once this identification step was completed, the intervention sample was established as the group of OP residing in Oportunidades beneficiary households, and the control sample as those residing in non-beneficiary households.Being the first time that data was gathered specifically on OP within the states constituting the original Oportunidades. Original design did not include the population of older adults as an interest group in which to evaluate Oportunidades effect, so that a module to measure the specific health issues of the older people was not included in any of the previous evaluation surveys, until 2007. In this sense, the strategy used in this study was to identify the households that were in 2007 currently receiving program benefits, and within the same localities identify households at the time that were not beneficiaries of the program. In such a way, that the intervention and control groups were defined according to the status of membership in the program they had during the fieldwork ENCEL 2007.It is important to note that this definition of the control group was necessary because of the original evaluation design of Oportunidades, the study applied the Propensity Score Matching technique [Oportunidades enrollment given a set of covariates, and the caliper matching algorithm allowed us to match, one-to-one, enrolled and not-enrolled EP with similar propensity scores [Given the probable incidence of numerous heterogeneous characteristics among the two groups, particularly in regards to their affiliation to echnique  to estimy scores ,36.Oportunidades enrollees and people not enrolled in the program [a| − |b|)/|a|), where a is the balance before and b is the balance after matching. Prior research indicated that these matching procedures lead to results similar to those obtained under the randomized experimental design built into the first stage of the Oportunidades program [To ensure comparability, we tested the balancing property on pre-treatment covariates between  program . We foll program ,39 to fi program .logit or probit models, alternate procedures for analyzing dichotomous variables. The linear probability model provides the advantage that its coefficients can be directly interpreted in terms of a change in the probability of the event of interest caused by the exposure variable. As the standard error estimators under the linear probability model are heteroskedastic we used robust standard errors [For each of the three dependent variables selected for the study  and for the dichotomous variable that defines the complete schedule vaccination, we used a separate linear probability models , which pd errors . All anad errors  and Statd errors .Instituto Nacional de Salud Pública) approved the Oportunidades evaluation. Participants received a detailed explanation of the procedures and signed an informed consent declaration before data collection occurred.The Research and Ethics Committees of Mexico’s National Institute of Public Health  were excluded because they displayed cognitive impairment or other disabilities and did not have caregivers. From the remaining, 4628 were matched  was observed on the influenza vaccine. Under the aforementioned linear probability model, this means that influenza immunization coverage was almost 7% higher among Oportunidades OP beneficiaries than among OP non-beneficiaries. Pneumococcal and tetanus vaccine results were analogous with coefficient values of 0.072  and 0.066 , respectively. Lastly, the program increased the probability of receiving the complete vaccination schedule   and a different number of treated and control units. These same analyzes were repeated using different ways to sort our observations. First ordering observations according to the unique identifier of household used in the survey, and second according to the household assets index. The results of these analyzes are shown in Table Since late 1990, CCT programs have been implemented and evaluated in Latin America and the Caribbean. The main feature of such programs is the provision of monetary support and investment in human capital, and in return the beneficiaries must meet certain actions that promote good health and nutrition, and increase their educational levels.Oportunidades. However, several systematic reviews on the impact of CCT programs, have found an increase in the use of health services for diverse populations , and a decrease on diarrhea in children, and the percentage of mothers who reported illness in children [Much of the empirical support on the impact of CCT programs on health and nutrition comes from studies evaluating children ,46.Familias en Acción program (Colombia) increased the probability that children have complied with the DPT vaccination schedule [Asignación Familiar program (Honduras) showed an increase in immunization coverage of DPT-Pentavalent in children less than three years [Red de Protección Social (Nicaragüa) led to large increases in complete schedule vaccination coverage [Oportunidades program showed a positive effect on the application of BCG in children aged 12–23 months and an increase in vaccination coverage against measles in children 12–23 months [In another vein, the impact of CCT programs on the prevalence of vaccination has been studied primarily in children. For example, the schedule , while tee years . Meanwhicoverage . Finally3 months .Oportunidades program and is based on a large sample of poor and rural elderly persons. To the best of our knowledge, it constitutes the first empirical effort aimed at investigating the association between CCT program participation and vaccination coverage for OP. According to the results, the participation of households with OP enrolled in Oportunidades, one of the largest CCT programs in the world, entailed a significant increase in the immunization coverage for the elderly with regard to tetanus, pneumococcal and influenza vaccines, and the complete vaccination schedule. It should be noted, however, that the immunization rates for this population continue to lag, particularly when compared to the standards established under the 2007–2012 Mexican National Health Plan [Our study, on the other hand, is part of the global evaluation of the lth Plan , where aWith respect to the hypothesis of our study, we believe that the program's effect is not only due to the mandatory six-monthly check-ups for the OP, but could be related to the fact that beneficiaries of the program have experienced a learning process regarding the use of services health, and the benefits that entails for health .Oportunidades program participation and vaccination coverage specifically and access to health services for the OP population in general. For instance, it is important to determine what roles other government institutions in Mexico  play in vaccination coverage. Further, beyond overall program participation, it is important for future research to identify specifically how the obligatory medical checkups required by Oportunidades affect vaccination.Additionally, the results of this study support the mounting evidence on the short-term benefits of CCT programs for various health indicators in low- and middle-income countries ,53-55. HActive ageing[Our results suggest that interventions to increase household income could increase vaccination coverage among OP. This could be an argument to promote interventions consisting in conditional cash transfers or non-contributory pension schemes for OP, which is expected to increase older people’s economic and physical autonomy. Autonomy is an essential component of older people’s well-being, to the extent that the World Health Organization in its ve ageing policy pOportunidades study with a methodology comparable to ours confirmed that analogous results are obtained under a quasi-experimental and a wholly experimental approach [Several limitations can be noted in our study. First, despite the rigorous matching methods applied to minimize the possibility of an OP selection bias regarding program participation, the causal inferences in the conclusions are not as powerful as they would have been had the study been executed under a purely experimental design. Notwithstanding, it is worth mentioning that another approach .Oportunidades and Non-Oportunidades) allowed for detecting differences of up to 3.5 percentage points with a power of 90%.Second, the study should be considered as a conservative estimate of program effects. Seeking to minimize selection bias, the original sample size and, consequently, the power of the study were cut down. Nonetheless, the final matched sample size (2314 OP in each group, Third, the self-reported vaccination status by the OP or his/her caregiver was estimated as the measure of the outcome variable. Again, while some studies have demonstrated the validity of self-report vaccination among various OP populations -59, the Oportunidades evaluation study in rural areas of Mexico was collected in 2007, just two years before the 2009 H1N1 influenza pandemic, which changed the public awareness of vaccination and the health literacy. In fact, for example, Mexico now has the highest rate of vaccination against influenza among OECD countries [Fourth, the data associated with the ountries . The impLastly, although the safety, effectiveness and cost-effectiveness of OP vaccination schedules have been documented , the dirOportunidades has an important effect in increasing vaccination rates in older people residing in rural areas of Mexico.The program of conditional cash transfer The authors declare that they have no competing interests.ASR BME had overall responsibility for the project and drafted the manuscript. ASR and BME participated in all phases of the design and implementation and were responsible for the design of survey questionnaires. ASR conducted the data analysis. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-698X/13/30/prepubEstimation and evaluation of the propensity score. Table 1a. Distribution of variables before and after matching. Figure 1a. Propensity score distribution before and after matching.Click here for file


Wuchereria bancrofti and Brugia malayiLymphatic filariasis (LF) is a debilitating vector-borne disease predominantly caused by the helminths In recognition of the worldwide burden of LF, in 1997, the World Health Assembly passed the resolution WHA 50.29 calling for collaborative efforts by member states to eliminate the disease as a public health problem Togo is one of the 34 African countries endemic for lymphatic filariasis and is surrounded by the endemic countries of Benin, Ghana, and Burkina Faso W. bancrofti and detects the presence of circulating filarial antigen (CFA) The Togolese Ministry of Health (MoH) used the Rapid Assessment of Geographical Distribution of Filariasis (RAGFIL) methodology, developed by the Special Programme for Research and Training in Tropical Diseases (TDR), to assess countrywide infection As accurate estimates of the national burden of LF morbidity are difficult to obtain, Mathieu and others described different methods to obtain LF morbidity prevalence in Togo Sentinel site data, cluster survey data, and the malaria bed net coverage survey data detected a hydrocele prevalence of 0.61% (95% CI 0.00–1.41), 0.63% (95% CI 0.20–1.06), and 2.6% (95% CI 1.8–3.4), respectively Shortly after the mapping, mass drug administration (MDA) campaigns were launched. All of Togo's LF districts are coendemic for onchocerciasis, and the communities with less than 2,000 inhabitants have been undergoing an annual or biannual MDA with ivermectin since the late 1980s The processes of drug distribution and reporting were facilitated by utilizing Togo's decentralized pyramidal health structure. A single community health worker (CHW) was selected to represent every 300 people in the endemic districts. As the first step toward calculating drug needs, the CHWs visited their respective households prior to each MDA in order to count all inhabitants. The results of the CHWs' annual census were used by the national coordinator to calculate drug needs. The NPELF requested ivermectin  and albendazole  from the Mectizan Donation Program (MDP). Drug distribution followed the reverse chain of reporting and ended with house-to-house distribution by the CHWs. As children under the age of five are ineligible to receive the treatment, the CHWs used a measuring stick to aid in age estimation and excluded all children with heights below 90 cm The first LF MDA was held in the district of Binah in 2000, and within three years, distributions scaled up to all seven endemic districts. Since 2004, reported drug coverage in each district has exceeded 80% of the total population . CoveragIn collaboration with the CDC and funded by IMA World Health-USAID, the Togo MoH engaged in an innovative approach to implement WHO-recommended lymphedema management techniques on a national scale (including the nonendemic districts). The lymphedema management program began in 2007 by training at least one staff member in each of the 570 health facilities in lymphedema education and care. This was followed by an awareness campaign to inform the population that care for “swollen legs" was available. Patients were trained in self-care by using WHO education materials that were locally adapted, and support structures for patients were created. The program sought to ensure sustainability beyond external funding by being low in cost and by including lymphedema treatment in standard medical training programs.Over the course of one year, the lymphedema management program scaled up to achieve national coverage. A total of 1,083 patients were enrolled into the program; approximately 30% of whom lived in nonendemic districts. An evaluation of the program, which was conducted three years after the launch, showed that 62% of the persons with a swollen leg, regardless of the cause or severity (reversible swelling was included), were still enrolled in the program.Another key element to success was participation in the multicountry West African LF Morbidity Project. Multiple workshops on the current WHO-recommended surgical techniques for hydrocele were held for district-level surgeons on an annual basis from 2005 to 2007 and then again in 2009. Following each workshop, surgical campaigns were conducted Since the program's inception, 24 district surgeons have participated in the surgical trainings. During the three campaigns that ran from 2005 to 2006, 257 hydrocelectomies were performed. In 2007 and 2008, 215 hydrocelectomies were performed with additional financial assistance from Health & Development International (HDI).The success of the NPELF was partially due to the rigorous monitoring and evaluation system.Following each annual drug distribution, reported drug coverage was collected using the participation tally submitted by the CHWs. The denominator used was the total population , which was calculated by the CHWs prior to each MDA. In each, the WHO's goal of 70% drug coverage was achieved, and since 2004, all districts' reported drug coverage has exceeded 80% see . In 2004A system of sentinel and spot-check sites was set up in the endemic districts in order to evaluate the impact of the MDA campaigns on microfilaremia. Seven sentinel sites were initially selected; due to budget constraints, the number of sites was later trimmed to three sites. Each of these three sites represented a cluster of districts. After the baseline collection in 2000, subsequent sentinel-site activities were conducted before the third and fifth year of MDA in each district. Blood samples were collected from 500 people in each sentinel site between the hours of 22:00 and 02:00. In adherence with WHO guidelines The baseline results from the sentinel sites indicated a microfilaremia prevalence between 1% and 36%. Since 2004, microfilaria samples from the sentinel sites see  and spotW. bancrofti, in addition to ten randomly selected slides per month, to the reference laboratory in Lomé.Togo is the first country to implement a nationwide LF surveillance system. Implemented in 2006, Togo put in place a system to identify and track cases with active infection. Forty laboratories were selected throughout the country for inclusion in surveillance activities. This system utilized nocturnal thick blood smears for malaria diagnosis, as they can concurrently be used to make LF diagnoses Within the first four years of the surveillance system, 8,050 slides were accrued by the reference laboratory and two LF-positive slides were identified. Both cases were followed up according to a predetermined algorithm of action, and no further positive cases followed. An evaluation of the system showed that some border areas were not as well covered. It was decided to increase the coverage of the surveillance system by implementation of centralized ELISA-based testing for antigenemia using filter-paper blood spots collected in dispensaries . No actiAdded components that contributed to the success of the NPELF were several operational research projects that further addressed the pillars of the GPELF and expanded program outreach.As mentioned, operational research implemented with the CDC's assistance resulted in the formation of Togo's national lymphedema program. One of the evaluation tools was a cohort survey (2004–2010) of 188 LF patients to assess impact. The survey addressed indicators such as current and previous treatment practices, quality of life, economic factors, and overall program impact among patients with lymphedema As the macrofilaremia in the sentinel sites and spot-check sites were <1%, the NPELF conducted a 30-cluster survey to establish interruption of disease transmission among children two and six years of age. In May 2008, the cluster survey was carried out with support from the Emory University LF Support Center, Atlanta following the WHO 2005 guidelines In 2006, the NPELF collaborated with the MDP and the CDC to develop an innovative ongoing national surveillance system. Several sampling modalities, such as using military recruits and blood banks, were considered, but it was decided to base the system on nocturnal thick smears collected to diagnose malaria as described above In 2012, the first post-MDA transmission assessment surveys (TAS) using the WHO's new guidelines In order to confirm the absence of recrudescence and prepare the country for certification, the post-MDA surveillance activities will continue until 2015. These activities include ongoing surveillance and the implementation of the second and final WHO-recommended TAS scheduled for 2015.In 2005, the NPELF also contributed to guide the global integrated NTD program by launching a three-year program supported by the CDC. The national NTD program coordinators developed an integrated NTD program during a one-year preparation phase to elaborate integrated tools and guidelines for an integrated NTD program. The integrated areas covered were mapping, baseline data, MDA, health education, and monitoring and evaluation. Thanks to a praziquantel donation from the Schistosomiasis Control Initiative (SCI), the integrated approach was twice piloted in the district of Binah and achieved good results. The coverage rates were high, program managers adhered to the concepts, and chances for sustainability were believed to be strengthened by linking unfunded NTD programs  with well-funded programs. Based on this success, the MoH was able to secure funding for a national scale-up.Furthermore, the NPELF program conducted operational research to validate drug coverage surveys with assistance from the MDP and the CDC. The accuracy of the results of such surveys was tested one, six, and 12 months after an MDA in Togo in which three drugs  were distributed. Survey results indicated that the respondents were able to accurately recall if they took the drugs.The main key to success in Togo was the mixture of an opportunistic approach from the NPELF combined with strategic and generous partners. Since the 1990s, Togo has been an underfunded country due to the political climate and subsequent digression from democracy This paper describes not only the first sub-Saharan LF program that probably interrupted transmission, but demonstrates that it is possible and essential for morbidity programs to be codeveloped along with the MDA campaigns in order to fully address the burden of the disease in endemic territories.The ability to implement an LF national program was not evident due to a variety of embargoes that were placed on Togo in the late 1990s. These embargoes kept the country in a state of severe economic stress. Although in this political climate LF was not perceived as a health priority, the dedication and endorsement of the concept of LF elimination by the MoH has, and continues to be, a critical factor in setting up a successful program. For example, during some years, the program was unable to provide the small MDA incentive of $3 to $6 USD per CHW volunteer. Regardless, the CHWs distributed the medications, motivated by the spirit of the collaborative environment created by the NPELF. Highly motivated CHWs also facilitated high compliance in the communities where LF was either largely unknown or not perceived as a health problem.A factor contributing to success was the fact that the MoH used existing structures. Indeed, the MDAs for LF elimination were initiated using the preexisting structure of the community-directed ivermectin treatment (CDTI) established by the national onchocerciasis control program Additionally, the NPELF demonstrated the ability to recognize and capture each funding opportunity to implement all components of the program. To date, the NPELF remains the only LF program in Africa that has been awarded financial aid from the GFATM. The collaboration with the CDC on several operational research projects enabled the program to implement some crucial aspects of the elimination program such as morbidity management and surveillance. It has also increased the visibility of the program and provided access to even more resources.It is also important to point out that the impact of this successful program is not limited to only alleviating the filariasis burden in Togo. The program was the base for RTI/USAID funding for an integrated NTD program resulting in finalizing national mapping The success of the NPELF in Togo shows that lymphatic filariasis can be effectively addressed in countries with limited funds when cooperative efforts combine with motivation and innovation. Ministries of health play a critical role in embracing the scaling up of program activities, and new avenues for partnerships and funding must be vigorously pursued. The main lesson learned is that when developing a national disease elimination strategy, a key component must be putting forth the time and effort to build strong collaborations among appropriate partners. This networking with program collaborators when combined with persistent advocacy and fundraising was the crucial component that permitted the NPELF to address LF in Togo.In conclusion, as summarized in In agreement with the new guidelines of the WHO


The development of a student exchange program was an essential part of the cooperation between the Medical Schools of the University of Goettingen (Germany) and the University of Thrace in Alexandroupolis (Greece). The student exchange program started in 2008 and was performed once a year. The experiences of this program and the feedback of participants are presented.Although organized by the Dept. of Thoracic, Cardiac, and Vascular Surgery, the approach of the program was multidisciplinary. Participants also attended Continuous Medical Education activities primary addressed to physicians. At the end of the program, the participants evaluated the program anonymously. The educational units were rated via a 4-grade system. Additionally, it was possible to comment both positive and negative aspects of the program.Twenty-nine educational units were evaluated. The practical teaching units yielded a better result than the classical teaching units . The Continuous Medical Education activities were evaluated less favorable .The student exchange program enhanced effective teaching and learning. Courses supporting practical medical skills were extremely positive evaluated. Continuous Medical Education activities are not suitable for students and therefore, we do not include such an event anymore. Additionally, the program created an excellent forum for contact and communication between the students of the two universities. Globalization and internationalization are two modern keywords, but they increasingly gain importance in many areas of social life. In this context, increased mobility and flexibility make globalized education mandatory and desirable. Therefore, it is extremely important to implement collaborations in medical education. Existing cooperation is based mostly on individual level but it is essential to establish cooperation at “higher” levels too; at university level the cooperation may be between institutes, departments, schools/faculties, or even between entire institutions. Beginning with cooperation on department level, in 2008 an enlarged cooperation between the Faculty of Medicine of the Georg-August University Goettingen (Germany) and the Medical School of the Democritus University of Thrace in Alexandroupolis (Greece) started. An important part of this cooperation was the development and the implementation of a student exchange program. Therefore, a group of 10 students from the German University were invited to Alexandroupolis for a week and consequently 10 students of the Greek University were invited to Goettingen two months later. The students from Goettingen visited Alexandroupolis in October and the students from Alexandroupolis came to Goettingen in December.The aims of this project were (i) the creation of a bi-national meeting forum for medical students, (ii) medical teaching and training using established and new teaching methods, (iii) the promotion of practical skills, and (iv) the increase of interest in medical research. This report presents the organization and the evaluation results of the second part of this program realized in Goettingen.rd, 4th, and 5th academic year. Conveniently, these students where hosted by the students from Goettingen, who, in turn, visited Greece themselves in October. The students were, furthermore, involved in the planning of the program. In addition to the teaching program, enough time was considered for social encounters and exchange.The student exchange program was performed in 3 consecutive years. Thirty-one medical students of the University in Alexandroupolis (10 men and 21 women) participated in the exchange to Goettingen. The students were in the 3The duration of the student exchange program was for the first and second program 8 days (from Monday to Monday) but for the third program a day more was added resulting in Sunday to Monday Figure .The educational program in Goettingen consisted of (i) lectures, (ii) seminars, (iii) bedside teaching , (iv) simulator teaching, (v) teaching in the operating room (OR), and (vi) workshops on basic surgical techniques. The lessons were taught mostly in English, occasionally in Greek or German. There have been a total of 29 teaching units Table . The conAt the end of the exchange program the educational units and the program itself were evaluated by the participants. One participant of the third program did not return the evaluation form. The evaluation was anonymous and the educational units were rated via a 4-grade system: (1) “very good”, 2) “good”, (3) “acceptable”, and (4) “poor”. In addition, there was the possibility to comment both positive and negative features/aspects  and parts of the internship . Such programs are based on the individual commitment of the students and their individual organizational ability. Furthermore, several other factors are important to the realization of this cooperation: the attractiveness of the host country and its non-medical environment, the reputation of the host country’s medicine, the program organization, and last but not least the costs . StudentBeyond the educational activity frame of internship and clerkship, European students may participate in an Erasmus program . SometimEducational contents were based on the Learning Curriculum of the Faculty of Medicine  . The objMoreover, the primary goal of the program, the establishment of a forum for the students of two universities, has proven a success. According to the comments of the participants communication was not only limited to learning and educational purpose. A few weeks after the student exchange program a Greek participant wrote in his blog: “… Another surprise for us was undoubtedly the daily live of our German fellow students; we can say that there is no student who does not practice at least one extracurricular activity. Many of them are active members of various voluntary, non-profit organizations. ....” , this coThe student exchange program was also challenging for the academic teachers. New ideas, new methods, and new perspectives enrich both, learning and teaching. The medical teachers applied and modified classical and modern teaching methods, stimulating learning, knowledge, and discussion. New knowledge can be incorporated either directly in the patient’s treatment, or indirectly through new innovative research projects.In general, the experience of the project showed that the organization and the coordination of such a program are very demanding and time-consuming. We could realize the program only through the individual commitment of the persons involved. For the success of such a program it is essential to give to the organizing persons enough space within the daily clinical work. For the future, we will ask the central academic institutions of the Faculty for technical support to improve the quality of coordination of the program. Nevertheless, we will keep the organization of the program in our hands to maintain a high degree of flexibility. Another important topic is the financing of such a project; oftentimes, this constitutes a major problem. Our program was primarily funded by the Department of Thoracic, Cardiac, and Vascular Surgery with the support from within the Faculty; the first time by the Department for International Relations of the Medical Faculty and the second time by the Dean’s Office. Finally, it was also important to give the program a formal frame; therefore, the participants of the program were welcomed to the University of Goettingen on the first day by both, the Dean (or Vice-Dean), and the director of the organizing Department. Moreover, in the evening, the mayor welcomed the students to Gottingen; this reception took place in the historic Town Hall.An important lesson learned was that issues of CME activities are not suitable for students, presumably because the topics were too specialized. Therefore, we do not include such an event anymore.Through the organization and implementation of an exchange program for medical students, we reached an excellent transfer of knowledge and created a meeting forum for open communication. The next goal of the academic cooperation will be the creation of common research projects.The authors declare that they have no competing interests.TT conceived of the study, participated in the design of the study, performed the data analysis, and drafted the manuscript. FAS participated in the design of the study and helped to draft the manuscript. Both authors read and approved the final manuscript.


The funding section is incomplete. The complete funding information is: "The authors acknowledge financial support from NIH U01 GM087719. JCM acknowledges support from the RAPIDD program of Department of Homeland Security and the NIH Fogarty International Center; and the United States National Institutes of Health Models of Infectious Disease Agent Study program through cooperative agreement 1U54GM088558. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."


Several organizations seek to address the growing burden of arthritis in developing countries by providing total joint replacements (TJR) to patients with advanced arthritis who otherwise would not have access to these procedures. Because these mission trips operate in resource poor environments, some of the features typically associated with high quality care may be difficult to implement. In the U.S., many hospitals that perform TJRs use the Blue Cross/Shield’s Blue Distinction criteria as benchmarks of high quality care. Although these criteria were designed for use in the U.S., we applied them to Operation Walk  Boston’s medical mission trip to the Dominican Republic. Evaluating the program using these criteria illustrated that the program provides high quality care and, more importantly, helped the program to find areas of improvement.We used the Blue Distinction criteria to determine if Op-Walk Boston achieves Blue Distinction. Each criterion was grouped according to the four categories included in the Blue Distinction criteria— “general and administrative”, “structure”, “process”, or “outcomes and volume”. Full points were given for criteria that the program replicates entirely and zero points were given for criteria that are not replicated entirely. Of the non-replicated criteria, Op-Walk Boston’s clinical and administrative teams were asked if they compensate for failure to meet the criterion, and they were also asked to identify barriers that prevent them from meeting the criterion.Out of 100 possible points, the program received 71, exceeding the 60-point threshold needed to qualify as a Blue Distinction center. The program met five out of eight “required” criteria and 11 out of 19 “informational” criteria. It scored 14/27 in the “general” category, 30/36 in the “structure” category, 17/20 in the “process” category, and 10/17 in the “outcomes and volume” category.Op-Walk Boston qualified for Blue Distinction. Our analysis highlights areas of programmatic improvement and identifies targets for future quality improvement initiatives. Additionally, we note that many criteria can only be met by hospitals operating in the U.S. Future work should therefore focus on creating criteria that are applicable to TJR mission trips in the context of developing countries. Improved longevity in developing countries has led to the rise of chronic diseases, including arthritis ,2. In deOrganizations that provide surgical care abroad seek to provide the highest quality care possible, although the effectiveness of these short-term medical mission programs has recently been debated . IdeallyThis report provides the first attempt to evaluate the quality of care offered by medical missions based on TJR quality standards from developed countries. We also demonstrate that this kind of evaluation can help medical mission organizations identify areas of programmatic improvement.The Dominican Republic is a small country  in the Caribbean Sea that shares the island of Espanola with Haiti. As of 2011, the country’s per capita income was approximately $9,300 . CitizenOp-Walk Boston is part of the national Operation Walk organization . The BosUsing the Blue Cross/ Shield’s selection criteria for Blue Distinction Centers for Knee and Hip Replacements, we determined if Op-Walk Boston’s joint replacement program meets the Blue Distinction criteria (scores at least 60 out of 100 possible points) . The stuFull points were awarded for criteria that the program replicates exactly and zero points were given for criteria that are not replicated. If a criterion was not applicable outside of the United States, zero points were awarded and the criterion was labeled “not applicable”. For all criteria that are not replicated, we interviewed a leader from each clinical and administrative team to see if they compensate for failing to meet the criterion by introducing an alternative strategy or process to enhance quality. We also interviewed these key informants to see if there are barriers that prevent them from adopting certain criteria.We classified the criteria as “General/Administrative”, “Process”, “Structure”, and “Outcomes and Volume” categories to follow widely-used frameworks for quality assessment  and to mIn the general criteria section, the program received 14 out of a possible 27 points  database to produce procedure specific performance reports and to tracking FDA-recalled prostheses and contacting patients with these prostheses. The hospital does not have a SCIP database and it also has difficulty tracking patients, which makes it difficult to contact patients whose prosthesis are recalled.In the structure category, the program was awarded 30 out of 36 possible points Table . The onlAside from the scorable criteria, there were also two criteria that were listed as “required” and seven listed as “informational”. The program met both of the required criteria and six of the informational criteria. It did not meet one informational criterion because it lacks pain management specialists who have subspecialty certification in pain management.The program received 17 out of 20 possible points in the process category (Table There are six informational criteria in the process category, and the program met three of them. One unmet criterion involved using shared decision making processes with patients. Another unmet criterion involved tracking op-notes and discharge forms to ensure the patient’s PCP receives the documents. The final unmet informational criterion involved using the Blue Cross/ Shield’s case management team to track transitions of care.In the outcomes and volume category, the program received 10 out of 17 possible points Table . The proThere are two required and two informational criteria in the outcomes and volume category. The program met both of the required criteria and did not meet either of the informational criteria. One informational criterion requests that the program publically report average lengths of stay for patients who need hip and knee revisions and the other criterion involves tracking selection, administration, and discontinuation of prophylactic antibiotics for knee replacements.The Op-Walk Boston program met enough criteria to score 71 of 100 possible points, exceeding the 60-point threshold needed to qualify as a Blue Center of Distinction (Figure Common barriers were identified that prevented some criteria from being met. First, many of the criteria require registration and participation in organizations that only exist in the United States or other developed countries. Second, many criteria were not met because they require frequent patient contact and PCP follow up. Third, some criteria require outcomes and patient tracking through online databases that are not currently available in many hospitals in the D.R.In this study, we evaluated the quality of the Op-Walk Boston’s TJR medical mission trip using the Blue Cross/ Shield’s Blue Distinction Criteria for Knee and Hip Replacement Centers. This analysis showed that the program scored 14/27 in the general/administrative scoring category, 30/36 in the structure category, 17/20 in the process category, and 10/17 in the outcomes and volume category. (Figure Although there is a growing body of quality assessment literature for medical mission trips in other fields , our stuIn addition to demonstrating quality, the process of evaluating the Op-Walk Boston program based on the Blue Distinction criteria helped generate ideas for quality improvement initiatives. For example, the program lost a point because it does not use patient navigators. Since Op-Walk Boston’s patients often have complex social needs and may have difficulties navigating the health care system, initiating a patient navigation program may help with the hospital experience and subsequent recovery. The program also lost a point because it does not evaluate patient’s discharge needs prior to their hospital admission. This is another area we have now identified for improvement. We plan to discuss with Op-Walk’s medical, nursing and rehabilitation colleagues in the Dominican Republic culturally acceptable ways of amplifying the patient's voice in decision making. Some of the barriers we identify could be overcome with greater funding. We have discussed our findings with administrative and clinical leaders in the Dominican Republic so that the observed deficiencies can be considered for funding in subsequent budgeting processes.When weighted scoring breakdowns were graphed according to the Blue Cross/Shield’s four major quality categories—general/administrative, structure, process, and outcomes and volume—the program’s general/administrative and outcomes and volume categories emerged as the weakest. Figure  These caIn the outcomes and volume category, the program lost 7 points mainly because its host hospital does fewer than 250 TJRs and 50 revisions procedures annually. When Op-Walk Boston first began working in the D.R., its host hospital performed fewer than 20 TJRs annually; volume has expanded to over 100 annually. Although it does not meet the 250 annual TJR threshold requested by the Blue Cross/Shield criteria, the host hospital has therefore made significant progress in terms of volume.Although the Blue Distinction criteria for joint replacement centers were created as quality standards for U.S. hospitals, using these criteria as a benchmark for evaluating TJR medical mission trips can help demonstrate care quality and identify areas of quality improvement. Since some aspects of the Blue Distinction criteria require organizations to report to US-based quality improvement organizations, future work should alter the existing criteria so that these organizations can earn points for reporting to equivalent international quality improvement organizations or provide waivers for organizations that operate in countries without equivalent quality improvement organizations. Furthermore, some Blue Distinction criteria require investment in patient navigators or expensive health care infrastructure, which is difficult because cost is a common barrier for most international medical missions. The criteria should therefore be redesigned so that they can be implemented with a level of investment more congruent with the resource capacity in the country being evaluated. Having a revised set of criteria could help medical mission trips better evaluate their own programs and allow them to enhance the care they provide. In the meantime, other international TJR mission programs might consider using the Blue Distinction criteria—or other similar criteria—to evaluate and improve their own programs, as our study demonstrates that these analyses can facilitate programmatic improvement.This study’s data were potentially subject to observer bias, as data were collected by an investigator rather than a research assistant blinded to the study’s hypotheses and objectives. Anticipating this bias, we used data elements from the Blue Cross/Shield’s excellence criteria that were objective, binary, and subject to little interpretation. Furthermore, the data for this study was collected from a small number of respondents who provided key information to evaluate if the program meets or does not meet the criteria; it is therefore possible that responses would have been more heterogeneous if more people were surveyed but this variability should be limited by the objective and binary nature of the Blue Cross/Shield’s criteria.Op-Walk Boston qualified for Blue Distinction. Our analysis highlights areas of programmatic improvement and identifies targets for future quality improvement initiatives. Additionally, we note that many criteria can only be met by hospitals operating in the U.S. Future work should therefore focus on creating criteria that are applicable to TJR mission trips in the context of developing countries.This study was approved by the IRBs at both the Brigham and Women’s Hospital in Boston and the Hospital General de la Plaza de la Salud in Santo Domingo.The authors of this manuscript report no relevant financial or other competing interests.Conception: KED; JNK, Design: KED; RG; DD; LA; CB; BA; MH; TST; JNK, Data collection: KED, Data analysis: KED; JNK, Manuscript draft & revision: KED; RG; DD; LA; CB; BA; MH; TST; JNK. All authors have approved the final version of this manuscript in its entirety.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/14/275/prepub


The current aims were to examine: (i) mobiletype as a clinical assistance tool, ii) doctor-patient rapport and, iii) pathways to care.GPs detect at best 50c of mental health problems in young people. Barriers to detecting mental health problems include lack of screening tools, limited appointment times and young people’s reluctance to report mental health symptoms to GPs. The mobiletype program as a clinical assistant tool. Doctor-patient rapport was assessed using the General Practice Assessment Questionnaire Communication and Enablement subscales, and the Trust in Physician Scale (TPS). Pathways to care was measured using The Party Project’s Exit Interview.We conducted a randomised controlled trial in primary care with patients aged 14 to 24 years recruited from rural and metropolitan general practices. GPs identified and referred eligible participants  who were randomly assigned to either the intervention group  or the attention-comparison group (where only daily activities were monitored). Both groups self-monitored for 2 to 4 weeks and reviewed the monitoring data with their GP. GPs, participants and researchers were blind to group allocation at randomisation. GPs assessed the Of the 163 participants assessed for eligibility, 118 were randomised and 114 participants were included in analyses . T-tests showed that the intervention program increased understanding of patient mental health, assisted in decisions about medication/referral and helped in diagnosis when compared to the attention-comparison program. Mixed model analysis showed no differences in GP-patient rapport nor in pathways to care.mobiletype has much to offer GPs in the often difficult and time-consuming task of assessment and management of youth mental health problems in primary care.We conducted the first RCT of a mobile phone application in the mental health assessment and management of youth mental health in primary care. This study suggests that NCT00794222ClinicalTrials.gov  Seventy-five percent of major mental disorders and alcohol or other substance misuse disorders have their onset prior to the age of 25 ,2. Adolemobiletype). The aim of the mobiletype program is to support doctors and provide information about young people’s general and more specific mental health functioning to assist in determining appropriate treatment approaches and management plans. It is a youth-friendly, time-saving mental health assessment which can be used at any time point within the patient care trajectory [The high prevalence of mental health symptoms amongst young people, as well as their reluctance to raise these subjects , suggestajectory -16. Mobiajectory .mobiletype program monitors a young person’s mood, stress, coping strategies and daily activities a number of times per day, and their eating, sleeping, exercise patterns and alcohol and cannabis use once per day. This information is then uploaded to GPs, via a secure website and displayed in summary reports for review, in a manner similar to a pathology or radiology report [mobiletype program assisted the doctor to understand the young person better [The y report . Our stun better ,18.mobiletype program [mobiletype program in the real world primary care setting and therefore sought to have broad inclusion criteria such that the findings may best approximate the nature of the primary care setting. This paper reports on the health service outcomes of the RCT , ii) does the mobiletype program enhance doctor-patient rapport compared to an attention-comparison, iii) and does the mobiletype program assist in leading young people into pathways to care for mental health symptoms compared to an attention-comparison?The overall aim of this study was to investigate, via a randomised controlled trial, a number of suggested benefits found in our pilot studies of the  program -16,19, bPractice ), the foAs the present reports on the secondary outcomes of a larger RCT, a full description of methodology is reported elsewhere .mobiletype randomised controlled trial conducted from 2009 to 2011. This was a multi-centre, multi-regional, stratified (according to region), single blind, attention-controlled study with balanced (1:1) individual randomisation into parallel-groups. This study was conducted in Victoria, Australia in a manner to allow for strict adherence to CONSORT reporting guidelines [The data presented here are the secondary outcome data from the http://www.mgpn.com.au). Participating GPs were trained in using the mobiletype website and the study procedure, and provided a thorough range of clinical support and literature. Continuing professional development quality assurance points were available to GPs for their participation in the study. Weekly reminder faxes were sent to all participating GPs and fortnightly phone calls to the GPs clinic were made to remind doctors of the study and to provide an update on recruitment to the study.All general practitioners in the Goulburn Valley Region and the Albury/Wodonga Region were invited to participate in the study via the Regional Division of General Practice . GPs in Melbourne were recruited via the local Divisions of General Practice. Clinics were targeted that listed an interest in adolescent health on the Melbourne General Practice Network  aged 14 to 24 years, (2) speak proficient English and (3) have a mild or more severe emotional/mental health issue as assessed by their GP, or indicated by a K10 Symptom score greater than 16 . Particimobiletype program was used as the intervention in this study which was created using Java Platform, Micro Edition, in-house by the Murdoch Childrens Research Institute. This program was written for use with multiple models of mobile phones and firmware. For the purposes of this trial participants were lent a study mobile phone with either the mobiletype intervention or comparison program downloaded onto it.Version 4 of the mobiletype entry by an auditory signal/beep emitted from the mobile phone at random intervals in the blocks outlined in Table Participants were prompted to complete a mobiletype program which assessed 8 areas of functioning as developed in previous mobiletype studies [The intervention group monitored themselves using the complete  studies ,19, consmobiletype program which assessed only current activities, location, companions, quality and quantity of sleep, and quantity and type of exercise, and diet. Importantly, the modules pertaining mental health as per Table The attention comparison group was designed to provide a data collection process similar to the intervention group by controlling for the amount of time spent engaged in the research methodology and the attention given to them by health care professionals and research staff . The commobiletype program (intervention and comparison) on the mobile phone were sent via SMS to a secure website constructed and hosted by MCRI, where it was automatically collated. Each area of assessment was displayed in graphs (i.e. daily mood graphs) or in tables . An individualised summary report of the data was written following structured prescriptive guidelines by the first author (registered psychologist), or the second author under the supervision of the first author. The intervention summary reports consisted of mood, stress and coping, maintaining wellbeing and useful resources and recommendations for the intervention group. The comparison group also received individualized summary reports consisting of maintaining wellbeing  and useful resources and recommendations. A copy of the summary report has been published previously [Data collected by the eviously .mobiletype as a clinical assistance tool, GP/patient rapport, and pathways to care.A full description of all outcome measures are reported in the main RCT outcome paper . The premobiletype assisted both the GP and the patient understand the patient’s current functioning, and was helpful with diagnosis, communication, maintaining trust, understanding patients’ specific medical problem, understanding patient’s mental health problems, knowledge about the patient , and gaining a good overall picture of their patient’s current functioning. At pre-test and post-test, GPs answered an adapted version of the SHO Appraisal Form [After the post-test medical review GPs completed a series of 5-point Likert scale items (0 = Very poor/unhelpful to 4 = Very well/helpful), concerning the extent to which sal Form . This mesal Form  and was Doctor-patient rapport was measured from the patients’ perspective with the General Practice Assessment Questionnaire (GPAQ) Communication and Enablement subscales , and theThe Party Project’s Exit Interview  was compRecruitment of 200 participants was anticipated from 10 general practices. This sample size was based upon Cohen’s  statistimobiletype monitoring intervention program group or ii) the comparison program group; both groups also received care as usual. Randomisation was carried out by an in-house computer programmer who had no research or recruitment role in the study using random seed generation at the individual-level and stratified according to area . Study mobile phones were allocated ID numbers within areas  and either the intervention or comparison mobiletype program was loaded consecutively in a blinded fashion according to the programmer’s concealed randomisation list. The randomisation list was constructed for 100 Melbourne, 50 Goulburn Valley and 50 Albury/Wodonga participants. Researchers, participants, and GPs were blind to randomisation pre-test. GPs and participants became aware of the group allocation at the post-test when the summary reports were reviewed. This study had Royal Children’s Hospital Human Research Ethics Committee approval (HREC: 28113), was registered in ClinicalTrials.gov (Reference: NCT00794222) and adhered to ethical guidelines for data collection, storage and reporting.Participants were randomised to either i) the mobiletype research assistant within five days of referral to learn the study process, complete consent forms, the pre-test questionnaire package, review the mobiletype program and other features of the phone and complete a practice entry of the mobiletype program. Participants were provided with a study manual that described the research procedure and offered trouble-shooting tips.In addition to treatment as usual, GPs screened their patients for eligibility to the study, organised an appointment for interested participants with a research. Participants met with a mobiletype program for the study period. Information regarding the development and testing of the mobiletype program has been previously published [mobiletype entries a day until they returned for their medical review in 2–4 weeks; participants and GPs were advised that 2–4 weeks was the ideal monitoring period. Participants were given a SIM card containing $30 in credit as partial reimbursement for their time and phone credit used.All participants borrowed a Sony Ericsson Z750i mobile phone containing the ublished . Particimobiletype website. Young people completed a post-test assessment immediately following this appointment, again at six weeks and six months after this post-test review . GPs completed a post-test questionnaire immediately after the appointment. Questionnaires were completed online, over the phone with a research assistant, or via a mailed hardcopy survey. Participants were given a $20 gift card for each follow up survey completed .Upon completion, participants reviewed the self-monitoring data with their GP on the Demographic data and missingness (to satisfy the MAR assumption for random-effects modeling) are reported elsewhere . For datFinally, for data measured at three timepoints , mixed model analysis was employed, using the MIXED procedure in SPSS (consistent with methodology carried out in the primary outcomes article ). ContraClustering at the GP level was considered and tested, but due to the number of GPs involved and the relatively small clusters within GPs, clustering at the GP level did not significantly contribute to the model or provide a better approximation of the intraclass correlation coefficient than at the individual level.In sum, the mean participant age was 18.1 years (SD = 3.2), and the majority were female (71.9%), students (66.7%) and did not identify with an ethnic background (87.3%). No significant demographic differences were found between groups, and the MAR assumption was upheld. Rural areas were purposefully overrepresented in this study with 26 different practices in the three recruitment areas: 12 in greater Melbourne, 7 in Wodonga and 7 in the Goulburn Valley.mobiletype program, independent t-tests compared responses of GPs’ with participants in the intervention group to those with patients in the comparison group. The results can be seen in Table To evaluate the effectiveness of the mobiletype program, their GPs found that the mobiletype program significantly assisted them in gaining a picture of their patient’s current functioning  than when participants completed the attention comparison program. Moreover, GPs reported that the mobiletype program was significantly more helpful in deciding about medication  and referrals  compared to the attention comparison. Finally, GPs indicated that the mobiletype program helped in their diagnosis  and communication , as well as their patient’s specific medical  and mental health problems , significantly more than when using the attention comparison.Results indicate that when participants completed the intervention p = .131).The difference between groups at post-test in the GP Confidence scale  were tested by regression analysis, adjusting for pre-test GP Confidence scale score. After adjusting for baseline values, the difference between intervention and comparison group’s doctors confidence was not significant  = 0.96, p = .386 and no significant main effect for group F = 0.89, p = .347, or time F = 0.09, p = .917. Similar results were found for the GPAQ Enablement subscale with nonsignificant group x time interaction, F = 0.18, p = .839, and main effects for group, F = 0.00, p = .992, and time, F = 2.73, p = .072. The final rapport-based scale, TPS (α = 0.71), also returned nonsignificant results, with no significant interaction F = 1.00, p = .375, or main effects for group, F = 0.34, p = .562 or time, F = 0.46, p = .631.Three rapport-based scales - GPAQ Communication and Enablement subscales, and TPS were tested by way of mixed model analysis. Observed means and standard deviations of these scales can be seen in Table F = 13.83, p < .001, but no significant group main effect, F = 0.25 p = .618. Furthermore, the interaction effect of group x time was not significant, F = 0.01, p = .995. Estimated means (and standard errors) from the mixed model analysis are shown in Figure The summed Pathways to Care scale was also tested by mixed model analysis. Results from the main effects showed a significant effect of time, mobiletype program in primary care, in particular the extent to which the mobiletype could provide clinical assistance, enhance doctor-patient rapport and lead to pathways to care. GPs reported that the mobiletype program assisted them to understand their patients’ current functioning, mental and physical health problems and assisted them with diagnoses, communication, medication, referrals and significantly more than the attention comparison. These findings suggest that a mobile phone monitoring program which captures and summarises detailed, specific mental health and more general health information in a time-efficient manner may assist GPs in their management of youth mental health problems. Interestingly, whilst there was reasonably high compliance with the monitoring protocol both in this study [mobiletype program was a useful way of transferring information between patient and doctor, there was no significant effect of the mobiletype program on doctor-patient rapport from the young person’s perspective when tested across time and compared to an attention comparison program. Finally, there was no significant effect of the mobiletype program on pathways to care, rather as reported in the mental health outcomes paper [The aim of this RCT was to examine the health service outcomes of the is study  and our is study ,18,19, aes paper  it appeamobiletype program via its design offers a solution to a number of the doctor and patient barriers in detecting and managing mental health. mobiletype is systematic in assessment, time-efficient, provides detailed mental and general health information, generally well-received by patients [mobiletype program as clinical assistance tool and adds to the growing literature on the acceptability and benefits of computerised screening in primary care to assist GPs [Assisting GPs in the assessment and management of youth mental health problems is critical ,12, and patients , low-cossist GPs ,33.mobiletype program did not assist doctor-patient rapport significantly more than attention comparison program. Nevertheless, both the mobiletype and the attention comparison program included monitoring and provision of feedback for doctors and participants to review. The review of personal monitoring data was the process that we hypothesised would lead to increased doctor-patient rapport, and hence a wait-list control group who did not monitoring may have been more appropriate comparison group to test this hypothesis. In addition, the participants ratings at pre-test of their satisfaction with their doctors was quite high, and anecdotally we found that many of the doctors volunteering for this study were experienced in working with young people and/or had an interest in mental health. Thus a ceiling effect may have occurred in terms of the ratings of doctor patient-rapport.It was surprising, given our pilot study findings  that usimobiletype program lead to a difference in the pathways to care compared to the attention comparison group. The significant main effect for time, suggested that GPs were unexpectedly acting to manage mental health during the pre-test review in two ways for the majority of participants, without waiting for further information from the mobiletype monitoring data, summary report and recommendations, and then were less likely to implement further pathways to care at post-test and 6-week post-test. As discussed in the mental health outcomes paper [Finally, we did not find that the es paper  participes paper ,34.mobiletype program as of greater clinical assistance than the attention comparison program, these results came from a onetime measurement point. The current study failed to find changes across time in GP confidence or doctor-patient rapport, and it is possible that our measures of GP confidence and doctor-patient rapport were insensitive to the changes that may have occurred. Moreover, our pre-test rapport and GP confidence scores were relatively high, also suggesting a possible ceiling effect that decreased the likelihood of improving these scores. An alternate reason for the lack of significance could be that study may have failed to attract doctors who are most in need of clinical assistance tools for the detection and assessment of mental health in young people. Research trials relying on volunteer participation tend to attract those who are interested and motivated by the topic of the research, in this case youth and mental health.Whilst the GPs rated the The inclusion of a wait-list control or “usual medical care only” group in this study would have allowed for comparison and testing of the doctor-patient rapport hypothesis, nevertheless, this was not the main hypothesis of the study. Finally, further limitations are detailed in the mental health outcomes paper , which imobiletype has much to offer GPs in the often difficult and time-consuming task of assessment and management of youth mental health problems in primary care.We conducted the first RCT of a mobile phone application in the mental health assessment and management of youth mental health in primary care. This study suggests that There are no competing interests for any authors in this publication.SCR conceived of, designed, and implemented the study, she also participated in the analyses and drafted the manuscript. SK participated in the conception, design, and implementation of the study, participated in the analyses and contributed to the drafting of the manuscript. SJCH conducted the analyses and participated in drafting the manuscript. AHDC coordinated the implementation of the study and contributed to drafting the manuscript. ASK contributed to the design of the study, collected data for the study and contributed to drafting the manuscript. LAS and GCP both contributed to the design of the study and drafting of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/14/84/prepub


A systematic review of primary prevention was conducted for cannabis use outcomes in youth and young adults. The aim of the review was to develop a comprehensive understanding of prevention programming by assessing universal, targeted, uni-modal, and multi-modal approaches as well as individual program characteristics. Twenty-eight articles, representing 25 unique studies, identified from eight electronic databases , were eligible for inclusion. Results indicated that primary prevention programs can be effective in reducing cannabis use in youth populations, with statistically significant effect sizes ranging from trivial (0.07) to extremely large (5.26), with the majority of significant effect sizes being trivial to small. Given that the preponderance of significant effect sizes were trivial to small and that percentages of statistically significant and non-statistically significant findings were often equivalent across program type and individual components, the effectiveness of primary prevention for cannabis use should be interpreted with caution. Universal multi-modal programs appeared to outperform other program types . Specifically, universal multi-modal programs that targeted early adolescents (10–13 year olds), utilised non-teacher or multiple facilitators, were short in duration (10 sessions or less), and implemented boosters sessions were associated with large median effect sizes. While there were studies in these areas that contradicted these results, the results highlight the importance of assessing the interdependent relationship of program components and program types. Finally, results indicated that the overall quality of included studies was poor, with an average quality rating of 4.64 out of 9. Thus, further quality research and reporting and the development of new innovative programs are required. Cannabis is the most widely used illicit drug worldwide As few researchers have posited what program components may lead to effective prevention of cannabis use, examination of the broader substance use literature may be informative in identifying key components for consideration. When attempting to prevent substance use in general, researchers have highlighted that theoretical models, program design, program facilitators, the developmental stage of participants, and program duration are key variables to consider for program efficacy To date, two meta-analyses and one systematic review have assessed cannabis use prevention specifically These reviews also are limited in that they focused exclusively on school-based  programs and did not differentiate between universal and targeted intervention programming. Recent developments in the primary prevention literature implicate the importance of multi-modal approaches that utilize family, peer, community, and school-based components There are a number of methodological considerations regarding the aforementioned meta-analyses and systematic review. All three reviews assessed quasi-experimental as well as experimental study designs. While this approach is reasonable, a sole focus on randomized controlled trials (RCTs) is suitable for systematic review as RCTs are more likely to provide unbiased information As such, the current study sought to extend existing literature by conducting a systematic review of cannabis use treatment outcomes in primary prevention research. The current review sought to determine the relative effectiveness of universal, targeted, uni-modal, and multi-modal programs, and to explore whether the effectiveness of these programs in deterring cannabis use differed as a function of participant age, program facilitators, program duration, program booster sessions, and program content. This study also assessed if study quality was associated with program effectiveness. The expectation was that a more comprehensive understanding would facilitate a more strategic and informed prevention approach to address the increasingly problematic prevalence of cannabis use in adolescent and youth populations.We conducted a comprehensive search of eight electronic databases  to identify relevant studies published between 1987 and January 2011. Key search terms were “cannabis* OR marijuana* or tetrahydrocannabinol” AND “adolescen* OR child* OR youth* OR young adult* OR student*” AND “prevention* OR early intervention* OR program evaluation* OR school-based*”  assessed cannabis use, (b) implemented the program as a primary prevention effort, (c) examined young people , and (d) presented original data. In addition, studies had to be RCTs published in a peer-reviewed journal in English. Overall, 49 RCTs reached the standards stipulated by the inclusion criteria. Two authors independently extracted data from eligible studies and discrepancies were resolved by discussion with a third author. Data information collected included the study design , demographic characteristics , intervention components, theoretical foundations, details of the outcome measures, statistical analysis procedures, and cannabis-specific outcomes. When a study did not report participants' ages, age was approximated from available information. For example, when a study reported a seventh grade sample, the average age of seventh grade students, 12 years, was used as an approximation. Additionally, when an age range was presented, the middle value of that range was documented.Study quality was assessed using an adapted version of the EPOC Risk of Bias criteria dd is defined as the difference between two means divided by the pooled standard deviation. According to To adequately compare the effectiveness of the primary prevention programs, standardized effect size estimates were calculated using Cohen's d and 95% CIs. When available, Cohen's d and CIs were reported as stipulated in the published papers or were calculated from means and standard deviations provided in the published papers. On occasion, however, the reported effect size estimate did not have corresponding confidence limits, or means and standard deviations were not reported. In these cases, an online effect size calculator d from standard errors and mean values, odds ratios, F-values, or chi-square values. For example, a ln(odds ratios) can be converted to an effect size estimate by dividing by 1.81 d and CIs. If authors were unable to provide required information or failed to reply to two email communications their study articles were subsequently excluded from this systematic review , with the remaining studies implemented in Australia (n = 2), the United Kingdom (n = 1), and Europe (n = 1). The number of participants varied considerably across prevention programs with baseline sample size ranging from 64 to 7079 . Although we attempted to extract data pertaining to theoretical foundations, a meaningful analysis was not feasible as insufficient information was reported to adequately differentiate programs based on theory. Overall, 28 articles were included in this systematic review, representing 25 unique RCTs. Most of the included studies were conducted in the United States (n = 15) did not report cannabis-specific content components. Rather, many of the studies reported targeting substance use in general or tobacco, alcohol, and other drugs in combination as content areas. Three studies  in comparison to 12 (63%) studies that did not include cannabis specific content .The majority of studies  of the 25 included studies reported some form of psychoeducation. Other typical content included social skills training , risk resiliency/refusal skills training , and decision making skills training . Six studies (24%) covered all four content areas, of which five reported statistically significant results . Five studies covered three of the four content areas, all of which reported statistically significant results . Nine studies included content for only two areas, of which four reported statistically significant results , and four studies reported inclusion of only one area, of which one was significant (d = 0.20). One study The vast majority  of the 25 included studies reported outcome measures relating to frequency of use. These measures were dichotomous or continuous and time intervals measured ranged from weekly use to lifetime use, with some studies assessing multiple time periods . Three studies reported alternate outcomes in addition to frequency of use, with one reporting stages of initiation Mdn = 2). Of the 25 studies, 13 (52%) did not present post-test data, while four (16%) reported post-test data only. Thirty-six percent (n = 9) of trials completed follow-up within one year, while 28% (n = 7) had follow-up tests for two years, and 20% (n = 5) had follow-up periods greater than two years post program implementation.The vast majority  utilized middle school students, with all except one d = 0.08 to 5.26, Mdn = 0.36). The universal program conducted by Schinke and colleagues d = 1.63 to 5.26, Mdn = 2.19). When excluding this study, the median effect size of the other significant findings reduced to 0.14.Of the set of 25 studies, 15 (60%) studies were universal prevention programs. The majority of these studies , ethnicity , athletic participation (n = 2), disease , and personality risk factors , with one study n = 5), medical clinics (n = 2), community organizations (n = 1), youth-oriented websites (n = 1), and radio and newspaper media advertisements (n = 1). Six (60%) of the targeted programs reported significant findings .The remaining ten studies (40%) were targeted prevention programs. These programs were targeted towards gender (n = 9). Other delivery modes included the family home d = 0.09 to 0.74, Mdn = 0.20), of which four were universal  and five were targeted .Uni-modal programs are those that adopted a single modality for prevention implementation. Fourteen (56%) studies utilized uni-modal program designs, of which seven (50%) were universal programs and seven (50%) were targeted. Many uni-modal programs were implemented in school settings (n = 9), with one study utilizing a college setting n = 7), with other programs utilizing, a CD-Rom intervention n = 8). The parent components would vary from intensive skills training workshops n = 2), community leadership/mentoring (n = 2), mass media coverage (n = 2), and school community development (n = 1). Of the eleven multi-modal programs, six reported significant findings , of which five were universal  and one was targeted . When excluding the Schinke and colleagues study The remaining 11 (44%) studies utilized multi-modal program designs, of which eight (73%) were universal programs and three (27%) were targeted. The primary sites for multi-modal program implementation were middle and high school settings (n = 14), middle adolescence , and late adolescence/young adult . Of those targeting early adolescence, ten (71%) programs yielded significant findings , whereas only five (56%) programs targeting middle adolescence yielded significant findings . No significant findings were reported for the late adolescence/young adult age group .Participant ages at baseline ranged from 11 to 21 years. Studies were divided into three categories to assess the optimal period of intervention: early adolescence  when excluding the Schinke and colleagues study n = 11) of facilitators in the included studies. Other programs utilized health professionals , peer leaders , parents , project workers , health educators , community role models , or were self-facilitated computer programs , with some studies opting to use multiple facilitators for program implementation . Two studies were excluded from this analysis of program facilitators as they collapsed their results across groups in their statistical analyses School teachers were the principal program facilitators accounting for 33% (n = 6) of teacher-facilitated programs reported significant results , compared to 37% (n = 7) of non-teacher facilitated programs , and 100% (n = 2) of programs utilizing multiple leaders . The non-teacher facilitated programs associated with statistically significant effect sizes were facilitated by project workers (n = 2), health professionals (n = 1), peer leaders (n = 1), parents (n = 1), or were self-facilitated computer programs (n = 2). The multiple facilitators programs utilized a teacher in combination with a project worker Of the 23 included studies, approximately 67%  and long programs . It is important to note, however, that the length of these sessions varied from approximately 13 minutes to 90 minutes, and that the total period of time taken to implement an intervention program varied from 1 day to 3 years. Seven (54%) of the programs categorized as short  and eight (67%) of the long programs  yielded significant findings. d = 0.70) rather than large. One long targeted uni-modal program yielded a statistically significant small effect size and another obtained statistically non-significant results in this category.Program duration was assessed according to the number of sessions delivered, divided into two categories: short programs  and those that did not (n = 16). Eighty-nine percent of programs that utilized boosters reported significant findings , in contrast to only 44% of programs that did not utilize boosters . Booster sessions were often implemented in addition to the core program sessions. The number of booster sessions ranged from 1 to 15, with specific information on session length, time of implementation, and content often not reported. For these reasons, studies were divided into two categories, those that implemented boosters , universal multi-modal , and targeted uni-modal  program designs, with lower quality reported for targeted multi-modal programs . The two highest quality studies were both conducted by Schinke and colleagues The two independent raters agreed on 97% of the quality scores. After discrepancies were resolved, quality scores ranged from 1 to 8, with an average quality rating of 4.64. This indicates that for many of of studies, half of the quality criteria were either not met. Quality ratings were consistent across universal uni-modal  and baseline characteristics (84%). A moderate percentage of studies scored positively on criteria assessing contamination (64%) and selective reporting (72%). In contrast, only half of all studies (52%) scored positively on the incomplete data criterion. The poor scores for incomplete data were a result of extremely high attrition rates, poor statistical treatment of missing data, or a lack of reporting. Of those studies scoring zero for poor attrition, attrition rates ranged from 23% to 47%, for follow-up periods from immediate post-test to 6 years.Quality scores were particularly problematic on criteria assessing program exposure, program adherence, blinding, and reliability of outcome measure with only 20%, 20%, 24%, and 40% of studies, respectively, scoring positively on these measures. While these scores could simply be a result of poor reporting, not being able to adequately assess these methodological components prevents a meaningful analysis of program curriculum.d range = 1.63 to 5.26), which may have overestimated the magnitude of median effect sizes. As such, results for categories where this study was included must be interpreted with caution as analysis without this study included often resulted in substantially smaller effects.This systematic review evaluated the effectiveness of primary prevention programs in averting young people from using cannabis. The current study extended knowledge gained from previous reviews by assessing the relative efficacy of universal, targeted, uni-modal, and multi-modal approaches, and evaluating whether the effectiveness of individual program components was related to program type. Overall, results suggest that primary prevention programs may be able to deter young people from using cannabis, with statistically significant effect sizes ranging from trivial (0.07) to extremely large (5.26). Despite this potential, evidence was largely inconclusive regarding a distinctive pattern of program efficacy as the percentages of statistically significant and non-statistically significant findings were often equivalent across program type and individual components. A consideration of the magnitude of statistically significant median effect size estimates, however, did reveal components that may more strongly influence program efficacy. The efficacy of these components must be interpreted with caution as they may be unreliable and biased given the equivalency of significant and non-significant data across categories, as well as the variability of study quality. Furthermore, a visual inspection of the data indicated that one study Most of the of studies included in this review did not include cannabis-specific content, hindering efforts to make conclusive statements about the relative efficacy of cannabis-specific versus general substance use prevention programming. Despite this, some programs were able to effectively prevent cannabis use for at least a short period. Tobler et al. Mdn d = 0.90 versus 0.17). As this study was of better quality than the others, universal multi-modal programs may be quite effective in preventing cannabis use when they are adopted and implemented as intended.Prior to this study, scarce research examining the relative efficacy of universal, targeted, uni-modal, and multi-modal programs existed, with the preponderance of cannabis-specific and general substance use prevention reviews and meta-analyses assessing universal school-based  approaches only. Overall, a consideration of statistically significant median effect size magnitudes revealed that universal multi-modal programs may be more effective in averting cannabis use than universal uni-modal, targeted uni-modal, and targeted multi-modal programs. Importantly, all three targeted multi-modal program studies were of poor quality, thus results pertaining to this category may be unreliable and should be interpreted with caution. Furthermore, the effectiveness of universal multi-modal studies appeared to be much greater when the study by Schinke and colleagues was included . While high levels of attrition, in general, cause a serious threat to internal and external validity Marked variability of statistical methodology, cannabis use outcomes, and follow-up periods across studies, rendered a meaningful meta-analysis untenable. Future research may benefit from the development of a standardized procedure for assessing cannabis use which stipulates the use of psychometrically verified assessments as well as a directive timeline for appropriate follow-up intervals. In addition, studies often failed to report important statistical information , which is required to calculate effect size and confidence interval values. Solely presenting traditional null hypothesis testing is no longer considered sufficient as it only provides information regarding statistical significance and does not facilitate a meaningful assessment of clinical or practical significance.Future research must become more rigorous in reporting important methodological program characteristics  and salient statistical information . The development of such procedures will not only enable a quantitative assessment of outcome data, which was not feasible in the current review, but will also facilitate a more rigorous assessment of all program components. In addition, results of the current study implicate the importance of assessing the inter-dependent relationship between individual program components and program type. Specifically, individual program components appeared to effect program efficacy as a function of program design. Thus, it seems pertinent that future research acknowledges the inter-dependent nature of different elements of program design and modifies assessment procedures to reflect these relationships. Furthermore, future research should evaluate the potential efficacy of universal multi-modal designs, targeting early adolescence, short in duration, implementing boosters, and utilizing non-teacher facilitators, rather than simply continuing to disseminate existing programs.In addition, research is needed to assess theoretical foundations for effective program development and to identify specific elements of effective program content and design. Prior research in the broader substance use literature Primary prevention strategies are often considered the most valuable approaches for targeting substance use as they can be extremely cost-effective The current review extended on previous literature by providing a broad-spectrum approach to assessing primary prevention program efficacy. The inclusion of universal and targeted programs, uni-modal and multi-modal strategies, in addition to the assessment of individual program components, facilitated a comprehensive synthesis of existing primary prevention strategies. In addition, given that cannabis is the most widely used illicit drug worldwide Nevertheless, there are several limitations that must be considered. First, the inclusion of only peer-reviewed published articles may have inadvertently biased prevention results, as studies reporting statistically significant findings are more likely to be published Overall, the current study suggests primary prevention programming may avert cannabis use. Albeit reliable and discernible patterns for program efficacy remain largely inconclusive, results of the current study implicate the importance of assessing the relative efficacy of all program types and the inter-dependent relationship of program type and individual program components. Substantial work is needed to improve the methodological and statistical reporting quality of effectiveness trials. The improvement of study quality in addition to continued research developing new models of prevention programs that consider the inter-dependent nature of individual program components will enable a successful approach to preventing cannabis use. Given the high prevalence of cannabis use in young people Appendix S1Search strategy for CINAHL (Ovid) 1987–2011. Limits included English language, peer reviewed and human.(DOCX)Click here for additional data file.Appendix S2Quality Criteria (adapted from EPOC Risk of Bias).(DOCX)Click here for additional data file.Appendix S3List of excluded eligible studies (n = 21).(DOCX)Click here for additional data file.