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1.  Age-Related Concerns of Male Veteran Callers to a Suicide Crisis Line 
In July 2007, the United States Department of Veterans Affairs (VA) partnered with the Department of Health and Human Services’ Substance Abuse and Mental Health Service Administration (SAMHSA) to create the Veterans Crisis Line (VCL) in order to meet the unique needs of Veterans in distress. The current study utilized a mixed methods design to examine characteristics of male callers to the VCL. Results from qualitative analyses demonstrated that the majority of callers between April 1 and August 31, 2008 contacted the VCL with concerns related to mental health issues, suicide ideation, and substance abuse issues. Quantitative analyses demonstrated age differences associated with concerns presented by callers such that middle-aged and older callers were more likely to present with loneliness and younger callers were more likely to present with mental health concerns. The results of this study will help to inform future research designed to optimize the effectiveness of the VCL for suicide prevention in Veterans.
doi:10.1080/13811118.2013.824842
PMCID: PMC4386687  PMID: 24810270
suicide; veterans; crisis line; hotline
2.  Characteristics of Veterans Accessing the Veterans Affairs Telephone Triage Who Have Depression or Suicidal Ideation: Opportunities for Intervention 
Objective
To characterize Veterans who call telephone triage because of suicidal ideation (SI) or depression and to identify opportunities for suicide prevention efforts among these telephone triage users using a biosurveillance application.
Introduction
Veterans accessing Veterans Affairs (VA) health care have higher suicide rates and more characteristics associated with suicide risk, including being male, having multiple medical and psychiatric comorbidities, and being an older age, compared with the general U.S. population. The Veterans Crisis Line is a telephone hotline available to Veterans with urgent mental health concerns; however, not all Veterans are aware of this resource. By contrast, telephone triage is a national telephone-based triage system used by the VA to assess and triage all Veterans with acute medical or mental health complaints.
Methods
The VA Electronic Surveillance System for Early Notification of Community-based Epidemics (ESSENCE) was queried for telephone triage calls during January 1–June 30, 2012. Calls were classified as SI or depression when the triage nurse selected SI or depression as the Veteran’s chief complaint from a set of fixed options. Demographic and recommended follow-up time and location information was reviewed. A random sample of 20 SI calls and 50 depression calls were selected for chart review to determine whether Veterans were examined in a clinic or followed up by a clinician by telephone within 2 weeks of the veteran’s call.
Results
During January 1–June 30, 2012, 253,573 total calls were placed to telephone triage. Among these calls, 2,460 unique Veterans placed 417 calls for SI and 2,290 calls for depression. This represents 1% (2,707/253,573) of all calls placed during the period. All encounter information is available in the surveillance application within 24 hours of the call being placed. Median age of callers was 55 years (range: 19–94); 86% were male; and 6% placed repeat calls. The median number of repeat calls was 2 (range: 2–10). Among the 2,707 calls for SI or depression, 1,286 (48%) were made after routine business hours (5:00 p.m.–8:00 a.m.), and 646 (24%) were made on weekends. The greatest proportion of calls were from Wisconsin and Northern Illinois (17%) and the Southeastern United States (14%). Among the 2,290 calls for depression, 1,401 callers (61%) were recommended for urgent follow up or within 24 hours. 771 (34%) were assigned a follow up location of an emergency department; 117 (5%) an urgent care; 1,332 (58%) a physician’s office or clinic; 52 (2%) self-care at home; and 18 (1%) were unspecified. Among the 417 calls for SI, callers 410 (98%) were recommended for urgent follow-up or within 24 hours. 330 (79%) were assigned a follow-up location of an emergency department; 38 (9%) an urgent care; 43 (10%) a physician’s office or clinic; 3 (1%) self-care at home; and 3 (1%) unspecified. Among the 20 SI and 50 depression calls for which the charts were reviewed, 1 (5%) SI call and 6 (12%) depression calls had no documented follow-up by telephone or in person with a clinician within 2 weeks of initial call.
Conclusions
Telephone triage represents an additional data source available to surveillance applications. Although telephone triage is not the traditional method provided by the VA for triage of urgent mental health concerns, >2,000 Veterans called it with acute symptoms of SI or depression during January–June 2012. Training for suicide prevention should be prioritized for operators working during the high-volume periods of off-hours and weekends when approximately half and one-quarter of calls were received, respectively. We recommend standard notification of suicide prevention coordinators regarding calls to telephone triage for SI or depression to prevent loss to follow-up among Veterans at risk for suicide. Further investigation into reasons for increased call burden in identified geographic areas also is recommended.
PMCID: PMC3692783
Surveillance; Veterans; Suicide Risk
3.  A Novel Brief Therapy for Patients Who Attempt Suicide: A 24-months Follow-Up Randomized Controlled Study of the Attempted Suicide Short Intervention Program (ASSIP) 
PLoS Medicine  2016;13(3):e1001968.
Background
Attempted suicide is the main risk factor for suicide and repeated suicide attempts. However, the evidence for follow-up treatments reducing suicidal behavior in these patients is limited. The objective of the present study was to evaluate the efficacy of the Attempted Suicide Short Intervention Program (ASSIP) in reducing suicidal behavior. ASSIP is a novel brief therapy based on a patient-centered model of suicidal behavior, with an emphasis on early therapeutic alliance.
Methods and Findings
Patients who had recently attempted suicide were randomly allocated to treatment as usual (n = 60) or treatment as usual plus ASSIP (n = 60). ASSIP participants received three therapy sessions followed by regular contact through personalized letters over 24 months. Participants considered to be at high risk of suicide were included, 63% were diagnosed with an affective disorder, and 50% had a history of prior suicide attempts. Clinical exclusion criteria were habitual self-harm, serious cognitive impairment, and psychotic disorder. Study participants completed a set of psychosocial and clinical questionnaires every 6 months over a 24-month follow-up period.
The study represents a real-world clinical setting at an outpatient clinic of a university hospital of psychiatry. The primary outcome measure was repeat suicide attempts during the 24-month follow-up period. Secondary outcome measures were suicidal ideation, depression, and health-care utilization. Furthermore, effects of prior suicide attempts, depression at baseline, diagnosis, and therapeutic alliance on outcome were investigated.
During the 24-month follow-up period, five repeat suicide attempts were recorded in the ASSIP group and 41 attempts in the control group. The rates of participants reattempting suicide at least once were 8.3% (n = 5) and 26.7% (n = 16). ASSIP was associated with an approximately 80% reduced risk of participants making at least one repeat suicide attempt (Wald χ21 = 13.1, 95% CI 12.4–13.7, p < 0.001). ASSIP participants spent 72% fewer days in the hospital during follow-up (ASSIP: 29 d; control group: 105 d; W = 94.5, p = 0.038). Higher scores of patient-rated therapeutic alliance in the ASSIP group were associated with a lower rate of repeat suicide attempts. Prior suicide attempts, depression, and a diagnosis of personality disorder at baseline did not significantly affect outcome. Participants with a diagnosis of borderline personality disorder (n = 20) had more previous suicide attempts and a higher number of reattempts.
Key study limitations were missing data and dropout rates. Although both were generally low, they increased during follow-up. At 24 months, the group difference in dropout rate was significant: ASSIP, 7% (n = 4); control, 22% (n = 13). A further limitation is that we do not have detailed information of the co-active follow-up treatment apart from participant self-reports every 6 months on the setting and the duration of the co-active treatment.
Conclusions
ASSIP, a manual-based brief therapy for patients who have recently attempted suicide, administered in addition to the usual clinical treatment, was efficacious in reducing suicidal behavior in a real-world clinical setting. ASSIP fulfills the need for an easy-to-administer low-cost intervention. Large pragmatic trials will be needed to conclusively establish the efficacy of ASSIP and replicate our findings in other clinical settings.
Trial registration
ClinicalTrials.gov NCT02505373
In a randomized controlled trial, Konrad Michel and colleagues test the efficacy of a manual-based therapy intended to prevent repeat suicide attempts.
Editors' Summary
Background
Suicide is a serious public health problem. Over 800,000 people worldwide die by suicide every year. In the US, one suicide death occurs approximately every 12 minutes. While the causes of suicide are complex, the goals of suicide prevention are simple—reduce factors that increase risk, and increase factors that promote resilience or coping. Factors that increase suicide risk include family history of suicide, family history of child abuse, previous suicide attempts, history of mental disorders (particularly depression), history of alcohol and substance abuse, and access to lethal means. Factors that are protective against suicide include effective clinical care for mental, physical, and substance abuse disorders; connectedness to family and community; and problem solving and conflict resolution skills. A previous suicide attempt is the main risk factor for repeat attempts and for completed suicide. Fifteen to 25 percent of people who attempt suicide make another attempt, and five to ten percent eventually die by suicide.
Why Was This Study Done?
A number of suicide prevention treatments have been developed. Most of them involve therapy sessions and personal follow-up. While some of them have been shown to work in clinical trials—often with participants who have made a previous suicide attempt—few interventions have proven to be effective consistently in different settings. For this study, the researchers developed a treatment called Attempted Suicide Short Intervention Program (ASSIP) composed of three therapy sessions shortly after the suicide attempt and follow-up over two years with personalized mailed letters. They wanted the therapy part to be short, in order to provide a treatment that would allow a psychiatric service to cope with the large number of patients seen in the emergency department after a suicide attempt. The therapeutic elements of the treatment emphasized building an early therapeutic alliance, which would then serve as a basis (“anchoring”) for long-term outreach contact through regular letters. The therapy sessions and letters follow a detailed script, which the researchers developed into a manual that includes a step-by-step description of the highly structured treatment, checklists, handouts, and standardized letters for use by health professionals in various clinical settings. This study was done to test whether ASSIP can reduce suicidal behavior in addition to routine treatment.
What Did the Researchers Do and Find?
The researchers carried out a randomized clinical trial testing ASSIP in people who had attempted suicide (the majority by intentional overdosing) and been admitted to the emergency department of the Bern University General Hospital in Switzerland. Participants were randomly assigned to two groups. The treatment group received ASSIP in addition to treatment as usual (inpatient, day patient, and outpatient care as deemed appropriate by the hospital clinicians); the control group received a single structured assessment interview plus treatment as usual. The study objective was to evaluate—with follow-up questionnaires and health-care data—whether ASSIP can reduce the rate of repeated suicide attempt in the 24 months after a suicide attempt. The researchers also compared suicidal ideation (i.e., whether and how often participants had suicidal thoughts), levels of depression, and how often people were hospitalized between the two groups.
A total of 120 patients who had recently attempted suicide were randomly allocated to treatment as usual or treatment as usual plus ASSIP. The 60 ASSIP participants received three therapy sessions followed by regular contact over 24 months. During the first therapy session, the patient was prompted to tell the story of how he or she had reached the point of attempting suicide. Narrative interviewing is a key element of ASSIP’s patient-centered collaborative approach. The first session was videotaped, and parts were watched and discussed by patient and therapist during the second session, to recreate the experience of psychological pain and analyze how stress developed into suicidal action. During the final session, therapist and patient developed a list of long-term goals, warning signs, and safety strategies. These were printed and given to the patient in a credit-card-sized folded leaflet along with a list of telephone help numbers. Patients were told to carry both items at all times and to use them in the event of an emotional crisis. Over the subsequent two years, patients received six letters from their therapist reminding them of the risk of future suicidal crises and the importance of the collaboratively developed safety strategies.
During the 24 months of follow-up, one death by suicide occurred in each group, five repeat suicide attempts were recorded in the ASSIP group, and 41 repeat suicide attempts were recorded in the control group. ASSIP was associated with an approximately 80% reduced risk of repeat suicide attempt. In addition, ASSIP participants spent 72% fewer days in the hospital during follow-up. There was no difference in patient-reported suicidal ideation or in levels of depression.
What Do these Findings Mean?
The results show that ASSIP, administered in addition to the usual clinical treatment, was able to reduce suicidal behavior over 24 months in patients who had recently attempted suicide. The addition of ASSIP to usual treatment directly or its effect on repeat attempts might also reduce health care costs. The absence of effects on suicidal thoughts and depression is consistent with ASSIP’s objective to help people cope with crises as opposed to eliminating them. The study’s findings in a real-world clinical setting (a university hospital in the Swiss capital) are promising. They justify further testing in large clinical trials and diverse settings to answer conclusively whether and where ASSIP can reduce repeat suicide attempts, prevent deaths from suicide, and reduce health-care costs.
Additional Information
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001968.
National Action Alliance for Suicide Prevention has information on research prioritization for suicide prevention
There is also a supplemental issue of the American Journal of Preventive Medicine focused on research about suicide prevention
More information about suicide is available from ZEROSuicide http://zerosuicide.sprc.org/ and the Suicide Prevention Resource Center http://www.sprc.org/
The US Centers for Disease Control and Prevention has information on suicide
The UK Mental Health Foundation also has information on suicide
The page “About Suicide” from the American Foundation for Suicide Prevention has information on warning signs, risk factors, and statistics
The US National Suicide Prevention Lifeline offers help and information
The Bern University Hospital of Psychiatry has a page describing ASSIP for patients (in German)
The Finnish Association for Mental Health has a page describing ASSIP (in English)
doi:10.1371/journal.pmed.1001968
PMCID: PMC4773217  PMID: 26930055
4.  Yellow Fever in Africa: Estimating the Burden of Disease and Impact of Mass Vaccination from Outbreak and Serological Data 
PLoS Medicine  2014;11(5):e1001638.
Neil Ferguson and colleagues estimate the disease burden of yellow fever in Africa, as well as the impact of mass vaccination campaigns.
Please see later in the article for the Editors' Summary
Background
Yellow fever is a vector-borne disease affecting humans and non-human primates in tropical areas of Africa and South America. While eradication is not feasible due to the wildlife reservoir, large scale vaccination activities in Africa during the 1940s to 1960s reduced yellow fever incidence for several decades. However, after a period of low vaccination coverage, yellow fever has resurged in the continent. Since 2006 there has been substantial funding for large preventive mass vaccination campaigns in the most affected countries in Africa to curb the rising burden of disease and control future outbreaks. Contemporary estimates of the yellow fever disease burden are lacking, and the present study aimed to update the previous estimates on the basis of more recent yellow fever occurrence data and improved estimation methods.
Methods and Findings
Generalised linear regression models were fitted to a dataset of the locations of yellow fever outbreaks within the last 25 years to estimate the probability of outbreak reports across the endemic zone. Environmental variables and indicators for the surveillance quality in the affected countries were used as covariates. By comparing probabilities of outbreak reports estimated in the regression with the force of infection estimated for a limited set of locations for which serological surveys were available, the detection probability per case and the force of infection were estimated across the endemic zone.
The yellow fever burden in Africa was estimated for the year 2013 as 130,000 (95% CI 51,000–380,000) cases with fever and jaundice or haemorrhage including 78,000 (95% CI 19,000–180,000) deaths, taking into account the current level of vaccination coverage. The impact of the recent mass vaccination campaigns was assessed by evaluating the difference between the estimates obtained for the current vaccination coverage and for a hypothetical scenario excluding these vaccination campaigns. Vaccination campaigns were estimated to have reduced the number of cases and deaths by 27% (95% CI 22%–31%) across the region, achieving up to an 82% reduction in countries targeted by these campaigns. A limitation of our study is the high level of uncertainty in our estimates arising from the sparseness of data available from both surveillance and serological surveys.
Conclusions
With the estimation method presented here, spatial estimates of transmission intensity can be combined with vaccination coverage levels to evaluate the impact of past or proposed vaccination campaigns, thereby helping to allocate resources efficiently for yellow fever control. This method has been used by the Global Alliance for Vaccines and Immunization (GAVI Alliance) to estimate the potential impact of future vaccination campaigns.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Yellow fever is a flavivirus infection that is transmitted to people and to non-human primates through the bites of infected mosquitoes. This serious viral disease affects people living in and visiting tropical regions of Africa and Central and South America. In rural areas next to forests, the virus typically causes sporadic cases or even small-scale epidemics (outbreaks) but, if it is introduced into urban areas, it can cause large explosive epidemics that are hard to control. Although many people who contract yellow fever do not develop any symptoms, some have mild flu-like symptoms, and others develop a high fever with jaundice (yellowing of the skin and eyes) or hemorrhaging (bleeding) from the mouth, nose, eyes, or stomach. Half of patients who develop these severe symptoms die. Because of this wide spectrum of symptoms, which overlap with those of other tropical diseases, it is hard to diagnose yellow fever from symptoms alone. However, serological tests that detect antibodies to the virus in the blood can help in diagnosis. There is no specific antiviral treatment for yellow fever but its symptoms can be treated.
Why Was This Study Done?
Eradication of yellow fever is not feasible because of the wildlife reservoir for the virus but there is a safe, affordable, and highly effective vaccine against the disease. Large-scale vaccination efforts during the 1940s, 1950s, and 1960s reduced the yellow fever burden for several decades but, after a period of low vaccination coverage, the number of cases rebounded. In 2005, the Yellow Fever Initiative—a collaboration between the World Health Organization (WHO) and the United Nations Children Fund supported by the Global Alliance for Vaccines and Immunization (GAVI Alliance)—was launched to create a vaccine stockpile for use in epidemics and to implement preventive mass vaccination campaigns in the 12 most affected countries in West Africa. Campaigns have now been implemented in all these countries except Nigeria. However, without an estimate of the current yellow fever burden, it is hard to determine the impact of these campaigns. Here, the researchers use recent yellow fever occurrence data, serological survey data, and improved estimation methods to update estimates of the yellow fever burden and to determine the impact of mass vaccination on this burden.
What Did the Researchers Do and Find?
The researchers developed a generalized linear statistical model and used data on the locations where yellow fever was reported between 1987 and 2011 in Africa, force of infection estimates for a limited set of locations where serological surveys were available (the force of infection is the rate at which susceptible individuals acquire a disease), data on vaccination coverage, and demographic and environmental data for their calculations. They estimate that about 130,000 yellow fever cases with fever and jaundice or hemorrhage occurred in Africa in 2013 and that about 78,000 people died from the disease. By evaluating the difference between this estimate, which takes into account the current vaccination coverage, and a hypothetical scenario that excluded the mass vaccination campaigns, the researchers estimate that these campaigns have reduced the burden of disease by 27% across Africa and by up to 82% in the countries targeted by the campaigns (an overall reduction of 57% in the 12 targeted countries).
What Do These Findings Mean?
These findings provide a contemporary estimate of the burden of yellow fever in Africa. This estimate is broadly similar to the historic estimate of 200,000 cases and 30,000 deaths annually, which was based on serological survey data obtained from children in Nigeria between 1945 and 1971. Notably, both disease burden estimates are several hundred-fold higher than the average number of yellow fever cases reported annually to WHO, which reflects the difficulties associated with the diagnosis of yellow fever. Importantly, these findings also provide an estimate of the impact of recent mass vaccination campaigns. All these findings have a high level of uncertainty, however, because of the lack of data from both surveillance and serological surveys. Other assumptions incorporated in the researchers' model may also affect the accuracy of these findings. Nevertheless, the framework for burden estimation developed here provides essential new information about the yellow fever burden and the impact of vaccination campaigns and should help the partners of the Yellow Fever Initiative estimate the potential impact of future vaccination campaigns and ensure the efficient allocation of resources for yellow fever control.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001638.
The World Health Organization provides detailed information about yellow fever (in several languages), including photo stories about vaccination campaigns in the Sudan and Mali; it also provides information about the Yellow Fever Initiative (in English and French)
The GAVI Alliance website includes detailed of its support for yellow fever vaccination
The US Centers for Disease Control and Prevention provides information about yellow fever for the public, travelers, and health care providers
The UK National Health Service Choices website also has information about yellow fever
Wikipedia has a page on yellow fever that includes information about the history of the disease (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
doi:10.1371/journal.pmed.1001638
PMCID: PMC4011853  PMID: 24800812
5.  Barriers to dog rabies vaccination during an urban rabies outbreak: Qualitative findings from Arequipa, Peru 
PLoS Neglected Tropical Diseases  2017;11(3):e0005460.
Background
Canine rabies was reintroduced to the city of Arequipa, Peru in March 2015. The Ministry of Health has conducted a series of mass dog vaccination campaigns to contain the outbreak, but canine rabies virus transmission continues in Arequipa’s complex urban environment, putting the city’s 1 million inhabitants at risk of infection. The proximate driver of canine rabies in Arequipa is low dog vaccination coverage. Our objectives were to qualitatively assess barriers to and facilitators of rabies vaccination during mass campaigns, and to explore strategies to increase participation in future efforts.
Methodology/Principal findings
We conducted 8 focus groups (FG) in urban and peri-urban communities of Mariano Melgar district; each FG included both sexes, and campaign participants and non-participants. All FG were transcribed and then coded independently by two coders. Results were summarized using the Social Ecological Model. At the individual level, participants described not knowing enough about rabies and vaccination campaigns, mistrusting the campaign, and being unable to handle their dogs, particularly in peri-urban vs. urban areas. At the interpersonal level, we detected some social pressure to vaccinate dogs, as well as some disparaging of those who invest time and money in pet dogs. At the organizational level, participants found the campaign information to be insufficient and ill-timed, and campaign locations and personnel inadequate. At the community level, the influence of landscape and topography on accessibility to vaccination points was reported differently between participants from the urban and peri-urban areas. Poor security and impermanent housing materials in the peri-urban areas also drives higher prevalence of guard dog ownership for home protection; these dogs usually roam freely on the streets and are more difficult to handle and bring to the vaccination points.
Conclusions
A well-designed communication campaign could improve knowledge about canine rabies. Timely messages on where and when vaccination is occurring could increase dog owners’ perception of their own ability to bring their dogs to the vaccination points and be part of the campaign. Small changes in the implementation of the campaign at the vaccination points could increase the public’s trust and motivation. Location of vaccination points should take into account landscape and community concerns.
Author summary
Canine rabies was reintroduced in Arequipa, Peru in March 2015, a rare event in an area previously declared free of transmission. In Arequipa, annual mass dog vaccination is practiced as a preventive strategy, with additional campaigns being implemented since the recent detection of the virus. However, these additional efforts have not quelled the outbreak and low dog vaccination coverage is driving ongoing transmission. We conducted focus groups in urban and peri-urban areas of Arequipa to identify barriers to and facilitators of canine vaccination during mass campaigns. Based on our findings, communication campaigns should seek to increase knowledge about canine rabies and the vaccination campaign, and provide timely messages on where and when vaccination is occurring. Small changes at the campaign’s vaccination points could increase public’s trust. Finally, there are differences between urban and peri-urban areas, such as landscape and topography that affect participation in mass vaccination campaigns and that should be considered when selecting locations for vaccination points.
doi:10.1371/journal.pntd.0005460
PMCID: PMC5371379  PMID: 28306717
6.  Impact Monitoring of the National Scale Up of Zinc Treatment for Childhood Diarrhea in Bangladesh: Repeat Ecologic Surveys 
PLoS Medicine  2009;6(11):e1000175.
Charles Larson and colleagues find that 23 months into a national campaign to scale up zinc treatment for diarrhea in children under age 5 years, only 10% of children with diarrhea in rural areas and 20%–25% in urban/municipal areas were getting the treatment.
Background
Zinc treatment of childhood diarrhea has the potential to save 400,000 under-five lives per year in lesser developed countries. In 2004 the World Health Organization (WHO)/UNICEF revised their clinical management of childhood diarrhea guidelines to include zinc. The aim of this study was to monitor the impact of the first national campaign to scale up zinc treatment of childhood diarrhea in Bangladesh.
Methods/Findings
Between September 2006 to October 2008 seven repeated ecologic surveys were carried out in four representative population strata: mega-city urban slum and urban nonslum, municipal, and rural. Households of approximately 3,200 children with an active or recent case of diarrhea were enrolled in each survey round. Caretaker awareness of zinc as a treatment for childhood diarrhea by 10 mo following the mass media launch was attained in 90%, 74%, 66%, and 50% of urban nonslum, municipal, urban slum, and rural populations, respectively. By 23 mo into the campaign, approximately 25% of urban nonslum, 20% of municipal and urban slum, and 10% of rural under-five children were receiving zinc for the treatment of diarrhea. The scale-up campaign had no adverse effect on the use of oral rehydration salt (ORS).
Conclusions
Long-term monitoring of scale-up programs identifies important gaps in coverage and provides the information necessary to document that intended outcomes are being attained and unintended consequences avoided. The scale-up of zinc treatment of childhood diarrhea rapidly attained widespread awareness, but actual use has lagged behind. Disparities in zinc coverage favoring higher income, urban households were identified, but these were gradually diminished over the two years of follow-up monitoring. The scale up campaign has not had any adverse effect on the use of ORS.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Diarrheal disease is a significant global health problem with approximately 4 billion cases and 2.5 million deaths annually. The overwhelming majority of cases are in developing countries where there is a particularly high death rate among children under five years of age. Diarrhea is caused by bacterial, parasitic, or viral pathogens, which often spread in contaminated water. Poor hygiene and sanitation, malnutrition, and lack of medical care all contribute to the burden of this disease. Replacing lost fluids and salts is a cheap and effective method to rehydrate people following dehydration caused by diarrhea. Clinical trials show that zinc, as part of a treatment for childhood diarrhea, not only helps to reduce the severity and duration of diarrhea but also reduces the likelihood of a repeat episode in the future. Zinc is now included in the guidelines by the World Health Organization (WHO)/UNICEF for treatment of childhood diarrhea.
Why Was This Study Done?
Zinc treatment together with traditional oral rehydration salts therapy following episodes of diarrhea could potentially benefit millions of children in areas where diarrheal disease is prevalent. The “Scaling Up of Zinc for Young Children” (SUZY) project was established in 2003 to provide zinc treatment for diarrhea in all children under five years of age in Bangladesh. The project was supported by a partnership of public, private, nongovernmental organization, and multinational sector agencies during its scale up to a national campaign across Bangladesh. The partners helped to develop the scale-up campaign, produce and distribute zinc tablets, train health professionals to provide zinc treatment, and create media campaigns (such as advertisements in TV, radio, and newspapers) to raise awareness and promote the use of zinc for diarrhea. The researchers wanted to monitor how effective and successful the national campaign was at promoting zinc treatment for childhood diarrhea. Also, they wanted to highlight any potential problems during the implementation of health care initiatives in areas with deprived health systems.
What Did the Researchers Do and Find?
The researchers set up survey sites to monitor results from the first two years of the SUZY campaign. Four areas, each representing different segments of the population across Bangladesh were surveyed; urban slums, urban nonslums, municipal (small city), and rural. There are approximately 1.5 million children under the age of five across these sites. Households in each survey site were selected at random, and seven surveys were conducted at each site between September 2006 and October 2008—about 3,200 children with diarrhea for each survey. Over 90% of parents used private sector providers of drug treatment so the campaign focused on distribution of zinc tablets in the private sector. They were also available free of charge in the public health sector. TV and radio campaigns for zinc treatment rapidly raised awareness across Bangladesh. Awareness was less than 10% in all communities prelaunch and peaked 10 months later at 90%, 74%, 66%, and 50% in urban nonslum, municipal, urban slum, and rural sites, respectively. However, after 23 months only 25% of urban nonslum, 20% of municipal and urban slum, and 10% of rural children under five years of age were actually using zinc for childhood diarrhea. Use of zinc was shown to be safe, with few side-effects, and did not affect the use of traditional treatments for diarrhea. Researchers also found that many children were not given the correct ten-day course of treatment; 50% of parents were sold seven or fewer zinc tablets.
What Do These Findings Mean?
These findings show that the first national campaign promoting zinc treatment for childhood diarrhea in Bangladesh has had some success. Addition of zinc tablets for diarrhea treatment did not interfere with existing therapies. Mass media campaigns, using TV and radio, were useful for promoting health care initiatives nationwide alongside the education of health care providers and care-givers. The study also identified areas where more work is needed. Surveys in more remote, hard to reach sites in Bangladesh would provide better representation of the country as a whole. High awareness of zinc did not translate into high use. Repeated surveying in the same subdistricts may have overestimated actual awareness levels. Furthermore, mass media messages must link with messages from health care providers to help to reinforce and promote understanding of the use of zinc. A change in focus of media messages from awareness to promoting household decision-making may aid the adoption of zinc treatment for childhood diarrhea and improve adherence.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000175
The International Centre for Diarrhoeal Disease Research, Bangladesh Web site has information about the study
The World Health Organisation provides information on diarrhea
The study was sponsored by the Bill & Melinda Gates Foundation
doi:10.1371/journal.pmed.1000175
PMCID: PMC2765636  PMID: 19888335
7.  The African American Women and Mass Media (AAMM) campaign in Georgia: quantifying community response to a CDC pilot campaign 
Cancer causes & control : CCC  2015;26(5):787-794.
Purpose
To evaluate whether a culturally appropriate campaign using “Black radio” and print media increased awareness and utilization of local mammography screening services provided by the Centers for Disease Control and Prevention’s National Breast and Cervical Cancer Early Detection Program among African American women.
Methods
The evaluation used a quasi-experimental design involving data collection during and after campaign implementation in two intervention sites in GA (Savannah with radio and print media and Macon with radio only) and one comparison site (Columbus, GA). We used descriptive statistics to compare mammography uptake for African American women during the initial months of the campaign (8/08–1/09) with the latter months (2/09–8/09) and a post-campaign (9/09–12/09) period in each of the study sites. Comparisons of monthly mammogram uptake between cities were performed with multinomial logistic regression. We assumed a p value <0.05 to be significant.
Results
We observed an increase of 46 and 20 % in Savannah and Macon, respectively, from the initial period of the campaign to the later period. However, the increase did not persist in the post-campaign period. Analysis comparing monthly mammogram uptake in Savannah and Macon with Columbus showed a significant increase in uptake from the first to the second period in Savannah only (OR 1.269, 95 % CI (1.005–1.602), p = 0.0449).
Conclusions
Dissemination of health promotion messages via a culturally appropriate, multicomponent campaign using Black radio and print media was effective in increasing mammogram uptake in Savannah among low-income, African American women. Additional research is needed to quantify the relative contribution of campaign radio, print media, and community components to sustain increased mammography uptake.
doi:10.1007/s10552-015-0540-5
PMCID: PMC4484552  PMID: 25732344
African American; Breast cancer; Campaign; Evaluation; Mammography
8.  Significant Reduction of Antibiotic Use in the Community after a Nationwide Campaign in France, 2002–2007 
PLoS Medicine  2009;6(6):e1000084.
Didier Guillemot and colleagues describe the evaluation of a nationwide programme in France aimed at decreasing unnecessary outpatient prescriptions for antibiotics. The campaign was successful, particularly in reducing prescriptions for children.
Background
Overuse of antibiotics is the main force driving the emergence and dissemination of bacterial resistance in the community. France consumes more antibiotics and has the highest rate of beta-lactam resistance in Streptococcus pneumoniae than any other European country. In 2001, the government initiated “Keep Antibiotics Working”; the program's main component was a campaign entitled “Les antibiotiques c'est pas automatique” (“Antibiotics are not automatic”) launched in 2002. We report the evaluation of this campaign by analyzing the evolution of outpatient antibiotic use in France 2000–2007, according to therapeutic class and geographic and age-group patterns.
Methods and Findings
This evaluation is based on 2000–2007 data, including 453,407,458 individual reimbursement data records and incidence of flu-like syndromes (FLSs). Data were obtained from the computerized French National Health Insurance database and provided by the French Sentinel Network. As compared to the preintervention period (2000–2002), the total number of antibiotic prescriptions per 100 inhabitants, adjusted for FLS frequency during the winter season, changed by −26.5% (95% confidence interval [CI] −33.5% to −19.6%) over 5 years. The decline occurred in all 22 regions of France and affected all antibiotic therapeutic classes except quinolones. The greatest decrease, −35.8% (95% CI −48.3% to −23.2%), was observed among young children aged 6–15 years. A significant change of −45% in the relationship between the incidence of flu-like syndromes and antibiotic prescriptions was observed.
Conclusions
The French national campaign was associated with a marked reduction of unnecessary antibiotic prescriptions, particularly in children. This study provides a useful method for assessing public-health strategies designed to reduce antibiotic use.
Editors' Summary
Background
In 1928, Alexander Fleming discovered penicillin, the first antibiotic (a drug that kills bacteria). By the early 1940s, large amounts of penicillin could be made and, in the following decades, several other classes of powerful antibiotics were discovered. For a time, it looked like bacteria and the diseases that they cause had been defeated. But bacteria rapidly became resistant to these wonder drugs and nowadays, antibiotic resistance is a pressing public-health concern. Almost every type of disease-causing bacteria has developed resistance to one or more antibiotic in clinical use, and multidrug-resistant bacteria are causing outbreaks of potentially fatal diseases in hospitals and in the community. For example, multidrug-resistant Streptococcus pneumoniae (multidrug-resistant pneumococci or MRP) is now very common. S. pneumoniae colonize the nose and throat (the upper respiratory tract) and can cause diseases that range from mild ear infections to life-threatening pneumonia, particularly in young children and elderly people.
Why Was This Study Done?
For years, doctors have been prescribing (and patients have been demanding) antibiotics for viral respiratory infections (VRIs) such as colds and flu even though antibiotics do not cure viral infections. This overuse of antibiotics has been the main driving force in the spread of MRP. Thus, the highest rate of S. pneumoniae antibiotic resistance in Europe occurs in France, which has one of the highest rates of antibiotic consumption in the world. In 2001 France initiated “le plan national pour préserver l'efficacité des antibiotiques” to reduce the inappropriate use of antibiotics, particularly for the treatment of VRIs among children. The main component of the program was the “Antibiotiques c'est pas automatique” (“Antibiotics are not automatic”) campaign, which ran from 2002 to 2007 during the winter months when VRIs mainly occur. The campaign included an educational campaign for health care workers, the promotion of rapid tests for diagnosis of streptococcal infections, and a public information campaign about VRIs and about antibiotic resistance. In this study, the researchers evaluate the campaign by analyzing outpatient antibiotic use throughout France from 2000 to 2007.
What Did the Researchers Do and Find?
The researchers obtained information about antibiotic prescriptions and about the occurrence of flu-like illnesses during the study period from the French National Health Insurance database and national disease surveillance system, respectively. After adjusting for variations in the frequency of flu-like illnesses, compared to the preintervention period (2000–2002), the number of antibiotic prescriptions per 100 inhabitants decreased by a quarter over the five winters of the “Antibiotics are not automatic” campaign. The use of all major antibiotic classes except quinolones decreased in all 22 regions of France. Thus, whereas in 2000, more than 70 prescriptions per 100 inhabitants were issued during the winter in 15 regions, by 2006/7, no regions exceeded this prescription rate. The greatest decrease in prescription rate (a decrease of more than a third by 2006/7) was among children aged 6–15 years. Finally, although the rates of antibiotic prescriptions reflected the rates of flu-like illness throughout the campaign, by 2006/7 this relationship was much weaker, which suggests that fewer antibiotics were being prescribed for VRIs.
What Do These Findings Mean?
These findings indicate that the “Antibiotics are not automatic” campaign was associated with a reduction in antibiotic prescriptions, particularly in children. Because the whole French population was exposed to the campaign, these findings do not prove that the campaign actually caused the reduction in antibiotic prescriptions. The observed decrease might have been caused by other initiatives in France or elsewhere or by the introduction of a S. pneumoniae vaccine during the study period, for example. However, an independent survey indicated that fewer members of the public expected an antibiotic prescription for a VRI at the end of the campaign than at the start, that more people knew that antibiotics only kill bacteria, and that doctors were more confident about not prescribing antibiotics for VRIs. Thus, campaigns like “Antibiotics are not automatic” may be a promising way to reduce the overuse of antibiotics and to slow the spread of antibiotic resistance until new classes of effective antibiotics are developed.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000084.
This study is further discussed in a PLoS Medicine Perspective by Stephen Harbarth and Benedikt Huttner
The Bugs and Drugs Web site from the UK National electronic Library of Infection provides information about antibiotic resistance and links to other resources
The US National Institute of Allergy and Infectious Diseases provides information on antimicrobial drug resistance and on pneumococcal pneumonia
The US Centers for Disease Control and Prevention also have information on antibiotic resistance (in English and Spanish)
The European Surveillance of Antimicrobial Consumption Web site provides information on antibiotic consumption in European countries
Les antibiotiques c'est pas automatique provides information about the “Antibiotics are not automatic” campaign (in French)
Information on the Plan National pour Pérserver l'efficacité des antibiotiques is also available (in French)
doi:10.1371/journal.pmed.1000084
PMCID: PMC2683932  PMID: 19492093
9.  Suicide after Leaving the UK Armed Forces —A Cohort Study 
PLoS Medicine  2009;6(3):e1000026.
Background
Few studies have examined suicide risk in individuals once they have left the military. We aimed to investigate the rate, timing, and risk factors for suicide in all those who had left the UK Armed Forces (1996–2005).
Methods and Findings
We carried out a cohort study of ex-Armed Forces personnel by linking national databases of discharged personnel and suicide deaths (which included deaths receiving either a suicide or undetermined verdict). Comparisons were made with both general and serving populations. During the study period 233,803 individuals left the Armed Forces and 224 died by suicide. Although the overall rate of suicide was not greater than that in the general population, the risk of suicide in men aged 24 y and younger who had left the Armed Forces was approximately two to three times higher than the risk for the same age groups in the general and serving populations (age-specific rate ratios ranging from 170 to 290). The risk of suicide for men aged 30–49 y was lower than that in the general population. The risk was persistent but may have been at its highest in the first 2 y following discharge. The risk of suicide was greatest in males, those who had served in the Army, those with a short length of service, and those of lower rank. The rate of contact with specialist mental health was lowest in the age groups at greatest risk of suicide (14% for those aged under 20 y, 20% for those aged 20–24 y).
Conclusions
Young men who leave the UK Armed Forces were at increased risk of suicide. This may reflect preservice vulnerabilities rather than factors related to service experiences or discharge. Preventive strategies might include practical and psychological preparation for discharge and encouraging appropriate help-seeking behaviour once individuals have left the services.
Navneet Kapur and colleagues find that young men who leave the United Kingdom Armed Forces are at increased risk of suicide.
Editors' Summary
Background.
Leaving any job can be hard but for people leaving the armed forces the adjustment to their new circumstances can sometimes be particularly difficult. For example, ex-military personnel may face obstacles to getting a new job, particularly if they were injured in action. Some become homeless. Others turn to alcohol or drugs or suffer mental illnesses such as depression. These things probably aren't common but those who leave the armed forces might also be at higher risk of suicide than the general population.
Why Was This Study Done?
Serving members of the UK Armed Forces (the British Army, the Naval Service, and the Royal Air Force) have a lower rate of suicide than the general UK population. The lower rate is probably due to “the healthy worker effect” (i.e., workers tend to be healthier than the general population, since the latter includes people unable to work due to illness or disability). However, there are anecdotal reports that ex-military personnel are more likely to die by suicide than are members of the general population. If these reports are correct, then measures should be put into place to prepare people for leaving the Armed Forces and to provide more support for them once they have left the military. The authors of this new study say that no previous studies had systematically examined suicide risk in individuals leaving the Armed Forces. In this new study, therefore, the researchers examine the suicide rate, timing, and risk factors for suicide in a large group (cohort) of former members of the UK Armed Forces.
What Did the Researchers Do and Find?
The researchers linked data on everyone who left the UK Armed Forces between 1996 and 2005 with information on suicides collected by the National Confidential Inquiry into Suicide and Homicide. Since 1996, the Inquiry has been collecting information about all suicides (defined as cases where the coroner has given a verdict of suicide or of “undetermined death”) in the UK, including information about whether the deceased used mental health services in the year before they died. The aim of the Inquiry is to reduce the risk of suicides (and homicides) in the UK by improving the country's mental health services. Between 1996 and 2005, 233,803 people left the Armed Forces and 224 (nearly all men) died by suicide. The researchers' statistical analysis of these data indicates that the overall suicide rate in the ex-military personnel was similar to that in the general population. However, the risk of suicide in men aged 24 y or younger who had left the military was 2–3 times greater than that in the same age group in both the general male population and in men serving in the Armed Forces. The risk of dying by suicide was highest in the first 2 y after leaving the military but remained raised for several years. Risk factors for suicide among ex-military personnel included being male, serving in the Army, having a short length of service, and being of lower rank. Only a fifth of the ex-military personnel who committed suicide had been in contact with mental health services in the year before they died, and the rate of contact with these services was lowest among individuals in the age groups at the highest risk of suicide.
What Do These Findings Mean?
These findings indicate that young men leaving the UK Armed Forces are at increased risk of suicide, particularly shortly after leaving. The study was not able to prove the reason for this increased risk, but the authors suggest three main possibilities: (1) the stress of transitioning to civilian life, (2) exposure to adverse experiences while in the military, or (3) a vulnerability to suicide before entering the military. The study provides some evidence to support the third hypothesis—untrained personnel with short lengths of service have a particularly high risk of dying by suicide after leaving the military, suggesting that the increased suicide risk may reflect a pre-military vulnerability. The researchers suggest that practical and psychological preparation might be helpful for people leaving the Armed Forces and that appropriate help-seeking behavior could be encouraged in these individuals. In the UK, the National Health Service is currently piloting a community-based mental health service for military veterans, characterized by regional clinical networks involving partnerships of relevant experts.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000026.
This study is further discussed in a PLoS Medicine Perspective by Jitender Sareen and Shay-Lee Belik
The Manchester University Centre for Suicide Prevention provides information about the National Confidential Inquiry into Suicide and Homicide and about other research into suicide, and a list of useful Web sites and help lines for people going through crises
A recent article in the Observer newspaper by Mark Townsend discusses the problems facing UK military personnel when they leave the Armed Forces
Information about suicides among serving members of the UK Armed Forces is published by the Defence Analytical Services Agency
The UK National Health Service provides information about suicide, including statistics about suicide in the UK and links to other resources
MedlinePlus also provides links to further information and advice about suicide
The World Health Organization provides information on the global burden of suicide
doi:10.1371/journal.pmed.1000026
PMCID: PMC2650723  PMID: 19260757
10.  Implementation of an Intersectoral Program to Eliminate Human and Canine Rabies: The Bohol Rabies Prevention and Elimination Project 
Background
The province of Bohol, located in the Visayas islands region in the Philippines has a human population of 1.13 million and was the 4th highest region for human rabies deaths in the country, averaging 10 per year, prior to the initiation of the Bohol Rabies Prevention and Elimination Project (BRPEP).
Aims
The BRPEP was initiated in 2007 with the goal of building a sustainable program that would prevent human rabies by eliminating rabies at its source, in dogs, by 2010. This goal was in line with the Philippine National Rabies Program whose objective is to eliminate rabies by 2020.
Methods
The intersectoral BRPEP was launched in 2007 and integrated the expertise and resources from the sectors of agriculture, public health and safety, education, environment, legal affairs, interior and local government. The program included: increasing local community involvement; implementing dog population control; conducting mass dog vaccination; improving dog bite management; instituting veterinary quarantine; and improving diagnostic capability, surveillance and monitoring. Funding was secured from the national government, provincial, municipal and village units, dog owners, NGOs, the regional office of the WHO, the UBS Optimus Foundation, and the Global Alliance for Rabies Control. The BRPEP was managed by the Bohol Rabies Prevention and Eradication Council (BRPEC) under the jurisdiction of the Governor of Bohol. Parallel organizations were created at the municipal level and village level. Community volunteers facilitated the institution of the program. Dog population surveys were conducted to plan for sufficient resources to vaccinate the required 70% of the dogs living in the province. Two island-wide mass vaccination campaigns were conducted followed by “catch up” vaccination campaigns. Registration of dogs was implemented including a small fee that was rolled back into the program to maintain sustainability. Children were educated by introducing rabies prevention modules into all elementary schools in Bohol. Existing public health legislation at the national, provincial, and municipal level strengthened the enforcement of activities. A Knowledge, Attitude and Practices (KAP) survey was conducted in 2009 to evaluate the educational knowledge of the population. Increased surveillance was instituted to ensure that dogs traveling into and out of the province were vaccinated against rabies. Human and animal cases of rabies were reported to provincial and national authorities.
Key Results
Within the first 18 months of the BRPEP, human rabies deaths had decreased annually from 0.77 to 0.37 to zero per 100,000 population from 2007–2009. Between October 2008 and November 2010 no human and animal cases were detected. Increased surveillance on the island detected one suspected human rabies case in November 2010 and one confirmed case of canine rabies in April 2011. Two mass vaccination campaigns conducted in 2007 and 2008 successfully registered and vaccinated 44% and 70% of the dogs on the island. The additional surveillance activities enabled a mobilization of mop up vaccination activities in the region where the human and canine case was located. Due to the increased effective and continuous surveillance activities, rabies was stopped before it could spread to other areas on the island. The program costs totaled USD 450,000. Registration fees collected to maintain the program amounted to USD 105,740 and were re-allocated back into the community to sustain the program.
Author Summary
The Province of Bohol, Philippines has eliminated dog and human rabies in less than three years by empowering the community and implementing an intersectoral strategy. In 2006, Bohol ranked 4th highest in the Philippines for human rabies, averaging 10 deaths per year. Launched in 2007, the program utilized a social awareness campaign, dog population control, mass dog vaccination campaigns, improved dog bite management and veterinary quarantine, a new diagnostic laboratory, expanded surveillance, and the inclusion of education modules into the school curriculum. Improving community compliance to existing national and provincial rabies laws and engaging volunteers to help conduct the project was a key to success. The program, led by the Governor of Bohol, was administered through a group of departments working together at a provincial and local level, and supervised through the Office of the Provincial Veterinarian. Financial support came through the Governor and several NGOs including the Global Alliance for Rabies Control. The program is self-sustaining, through a small dog registration fee fed back into the program, through the continuing education of children in their classrooms, and through the dedicated efforts of over 15,000 staff and volunteers throughout the island.
doi:10.1371/journal.pntd.0001891
PMCID: PMC3516573  PMID: 23236525
11.  Regional Changes in Charcoal-Burning Suicide Rates in East/Southeast Asia from 1995 to 2011: A Time Trend Analysis 
PLoS Medicine  2014;11(4):e1001622.
Using a time trend analysis, Ying-Yeh Chen and colleagues examine the evidence for regional increases in charcoal-burning suicide rates in East and Southeast Asia from 1995 to 2011.
Please see later in the article for the Editors' Summary
Background
Suicides by carbon monoxide poisoning resulting from burning barbecue charcoal reached epidemic levels in Hong Kong and Taiwan within 5 y of the first reported cases in the early 2000s. The objectives of this analysis were to investigate (i) time trends and regional patterns of charcoal-burning suicide throughout East/Southeast Asia during the time period 1995–2011 and (ii) whether any rises in use of this method were associated with increases in overall suicide rates. Sex- and age-specific trends over time were also examined to identify the demographic groups showing the greatest increases in charcoal-burning suicide rates across different countries.
Methods and Findings
We used data on suicides by gases other than domestic gas for Hong Kong, Japan, the Republic of Korea, Taiwan, and Singapore in the years 1995/1996–2011. Similar data for Malaysia, the Philippines, and Thailand were also extracted but were incomplete. Graphical and joinpoint regression analyses were used to examine time trends in suicide, and negative binomial regression analysis to study sex- and age-specific patterns. In 1995/1996, charcoal-burning suicides accounted for <1% of all suicides in all study countries, except in Japan (5%), but they increased to account for 13%, 24%, 10%, 7%, and 5% of all suicides in Hong Kong, Taiwan, Japan, the Republic of Korea, and Singapore, respectively, in 2011. Rises were first seen in Hong Kong after 1998 (95% CI 1997–1999), followed by Singapore in 1999 (95% CI 1998–2001), Taiwan in 2000 (95% CI 1999–2001), Japan in 2002 (95% CI 1999–2003), and the Republic of Korea in 2007 (95% CI 2006–2008). No marked increases were seen in Malaysia, the Philippines, or Thailand. There was some evidence that charcoal-burning suicides were associated with an increase in overall suicide rates in Hong Kong, Taiwan, and Japan (for females), but not in Japan (for males), the Republic of Korea, and Singapore. Rates of change in charcoal-burning suicide rate did not differ by sex/age group in Taiwan and Hong Kong but appeared to be greatest in people aged 15–24 y in Japan and people aged 25–64 y in the Republic of Korea. The lack of specific codes for charcoal-burning suicide in the International Classification of Diseases and variations in coding practice in different countries are potential limitations of this study.
Conclusions
Charcoal-burning suicides increased markedly in some East/Southeast Asian countries (Hong Kong, Taiwan, Japan, the Republic of Korea, and Singapore) in the first decade of the 21st century, but such rises were not experienced by all countries in the region. In countries with a rise in charcoal-burning suicide rates, the timing, scale, and sex/age pattern of increases varied by country. Factors underlying these variations require further investigation, but may include differences in culture or in media portrayals of the method.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, almost one million people die by suicide globally; suicide is the fifth leading cause of death in women aged 15–49 and the sixth leading cause of death in men in the same age group. Most people who take their own life are mentally ill. For others, stressful events (the loss of a partner, for example) have made life seem worthless or too painful to bear. Strategies to reduce suicide rates include better treatment of mental illness and programs that help people at high risk of suicide deal with stress. Suicide rates can also be reduced by limiting access to common suicide methods. These methods vary from place to place. Hanging is the predominant suicide method in many countries, but in Hong Kong, for example, jumping from a high building is the most common method. Suicide methods also vary over time. For example, after a woman in Hong Kong took her life in 1998 by burning barbecue charcoal in a sealed room (a process that produces the toxic gas carbon monoxide), charcoal burning rapidly went from being a rare method of killing oneself in Hong Kong to the second most common suicide method.
Why Was This Study Done?
Cases of charcoal-burning suicide have also been reported in several East and Southeast Asian countries, but there has been no systematic investigation of time trends and regional patterns of this form of suicide. A better understanding of regional changes in the number of charcoal-burning suicides might help to inform efforts to prevent the emergence of other new suicide methods. Here, the researchers investigate the time trends and regional patterns of charcoal-burning suicide in several countries in East and Southeast Asia between 1995 and 2011 and ask whether any rises in the use of this method are associated with increases in overall suicide rates. The researchers also investigate sex- and age-specific time trends in charcoal-burning suicides to identify which groups of people show the greatest increases in this form of suicide across different countries.
What Did the Researchers Do and Find?
The researchers analyzed method-specific data on suicide deaths for Hong Kong, Japan, the Republic of Korea, Taiwan, and Singapore between 1995/1996 and 2011 obtained from the World Health Organization Mortality Database and from national death registers. In 1995/1996, charcoal-burning suicides accounted for less than 1% of all suicides in all these countries except Japan (4.9%). By 2011, charcoal-burning suicides accounted for between 5% (Singapore) and 24% (Taiwan) of all suicides. Rises in the rate of charcoal-burning suicide were first seen in Hong Kong in 1999, in Singapore in 2000, in Taiwan in 2001, in Japan in 2003, and in the Republic of Korea in 2008. By contrast, incomplete data from Malaysia, the Philippines, and Thailand showed no evidence of a marked increase in charcoal-burning suicide in these countries over the same period. Charcoal-burning suicides were associated with an increase in overall suicide rates in Hong Kong in 1998–2003, in Taiwan in 2000–2006, and in Japanese women after 2003. Finally, the annual rate of change in charcoal-burning suicide rate did not differ by sex/age group in Taiwan and Hong Kong, whereas in Japan people aged 15–24 and in the Republic of Korea people aged 25–64 tended to have the greatest rates of increase.
What Do These Findings Mean?
These findings show that charcoal-burning suicides increased markedly in several but not all East and Southeast Asian countries during the first decade of the 21st century. Moreover, in countries where there was an increase, the timing, scale, and sex/age pattern of the increase varied by country. The accuracy of these findings is likely to be limited by several aspects of the study. For example, because of the way that method-specific suicides are recorded in the World Health Organization Mortality Database and national death registries, the researchers may have slightly overestimated the number of charcoal-burning suicides. Further studies are now needed to identify the factors that underlie the variations between countries in charcoal-burning suicide rates and time trends reported here. However, the current findings highlight the need to undertake surveillance to identify the emergence of new suicide methods and the importance of policy makers, the media, and internet service providers working together to restrict graphic and detailed descriptions of new suicide methods.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001622.
A PLOS Medicine research article by Shu-Sen Chang and colleagues investigates time trends and regional patterns of charcoal-burning suicide in Taiwan
The World Health Organization provides information on the global burden of suicide and on suicide prevention (in several languages); it also has an article on international patterns in methods of suicide
The US National Institute of Mental Health provides information on suicide and suicide prevention
The UK National Health Service Choices website has detailed information about suicide and its prevention
MedlinePlus provides links to further resources about suicide (in English and Spanish)
The International Association for Suicide Prevention provides links to crisis centers in Asia
The charity Healthtalkonline has personal stories about dealing with suicide
doi:10.1371/journal.pmed.1001622
PMCID: PMC3972087  PMID: 24691071
12.  Proceedings of the 3rd Biennial Conference of the Society for Implementation Research Collaboration (SIRC) 2015: advancing efficient methodologies through community partnerships and team science 
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G. | Aarons, Gregory A. | Malte, Carol A. | Lott, Aline | Saxon, Andrew J. | Boyd, Meredith | Scott, Kelli | Lewis, Cara C. | Pierce, Jennifer D. | Lorthios-Guilledroit, Agathe | Richard, Lucie | Filiatrault, Johanne | Hallgren, Kevin | Crotwell, Shirley | Muñoz, Rosa | Gius, Becky | Ladd, Benjamin | McCrady, Barbara | Epstein, Elizabeth | Clapp, John D. | Ruderman, Danielle E. | Barwick, Melanie | Barac, Raluca | Zlotkin, Stanley | Salim, Laila | Davidson, Marnie | Bunger, Alicia C. | Powell, Byron J. | Robertson, Hillary A. | Botsko, Christopher | Landes, Sara J. | Smith, Brandy N. | Rodriguez, Allison L. | Trent, Lindsay R. | Matthieu, Monica M. | Powell, Byron J. | Proctor, Enola K. | Harned, Melanie S. | Navarro-Haro, Marivi | Korslund, Kathryn E. | Chen, Tianying | DuBose, Anthony | Ivanoff, André | Linehan, Marsha M. | Garcia, Antonio R. | Kim, Minseop | Palinkas, Lawrence A. | Snowden, Lonnie | Landsverk, John | Sweetland, Annika C. | Fernandes, Maria Jose | Santos, Edilson | Duarte, Cristiane | Kritski, Afrânio | Krawczyk, Noa | Nelligan, Caitlin | Wainberg, Milton L. | Aarons, Gregory A. | Sommerfeld, David H. | Chi, Benjamin | Ezeanolue, Echezona | Sturke, Rachel | Kline, Lydia | Guay, Laura | Siberry, George | Bennett, Ian M. | Beidas, Rinad | Gold, Rachel | Mao, Johnny | Powers, Diane | Vredevoogd, Mindy | Unutzer, Jurgen | Schroeder, Jennifer | Volpe, Lane | Steffen, Julie | Dorsey, Shannon | Pullmann, Michael D | Kerns, Suzanne E. U. | Jungbluth, Nathaniel | Berliner, Lucy | Thompson, Kelly | Segell, Eliza | McGee-Vincent, Pearl | Liu, Nancy | Walser, Robyn | Runnals, Jennifer | Shaw, R. Keith | Landes, Sara J. | Rosen, Craig | Schmidt, Janet | Calhoun, Patrick | Varkovitzky, Ruth L. | Landes, Sara J. | Drahota, Amy | Martinez, Jonathan I. | Brikho, Brigitte | Meza, Rosemary | Stahmer, Aubyn C. | Aarons, Gregory A. | Williamson, Anna | Rubin, Ronnie M. | Powell, Byron J. | Hurford, Matthew O. | Weaver, Shawna L. | Beidas, Rinad S. | Mandell, David S. | Evans, Arthur C. | Powell, Byron J. | Beidas, Rinad S. | Rubin, Ronnie M. | Stewart, Rebecca E. | Wolk, Courtney Benjamin | Matlin, Samantha L. | Weaver, Shawna | Hurford, Matthew O. | Evans, Arthur C. | Hadley, Trevor R. | Mandell, David S. | Gerke, Donald R. | Prusaczyk, Beth | Baumann, Ana | Lewis, Ericka M. | Proctor, Enola K. | McWilliam, Jenna | Brown, Jacquie | Tucker, Michelle | Conte, Kathleen P | Lyon, Aaron R. | Boyd, Meredith | Melvin, Abigail | Lewis, Cara C. | Liu, Freda | Jungbluth, Nathaniel | Kotte, Amelia | Hill, Kaitlin A. | Mah, Albert C. | Korathu-Larson, Priya A. | Au, Janelle R. | Izmirian, Sonia | Keir, Scott | Nakamura, Brad J. | Higa-McMillan, Charmaine K. | Cooper, Brittany Rhoades | Funaiole, Angie | Dizon, Eleanor | Hawkins, Eric J. | Malte, Carol A. | Hagedorn, Hildi J. | Berger, Douglas | Frank, Anissa | Lott, Aline | Achtmeyer, Carol E. | Mariano, Anthony J. | Saxon, Andrew J. | Wolitzky-Taylor, Kate | Rawson, Richard | Ries, Richard | Roy-Byrne, Peter | Craske, Michelle | Simmons, Dena | Torrente, Catalina | Nathanson, Lori | Carroll, Grace | Smith, Justin D. | Brown, Kimbree | Ramos, Karina | Thornton, Nicole | Dishion, Thomas J. | Stormshak, Elizabeth A. | Shaw, Daniel S. | Wilson, Melvin N. | Choy-Brown, Mimi | Tiderington, Emmy | Smith, Bikki Tran | Padgett, Deborah K. | Rubin, Ronnie M. | Ray, Marilyn L. | Wandersman, Abraham | Lamont, Andrea | Hannah, Gordon | Alia, Kassandra A. | Hurford, Matthew O. | Evans, Arthur C. | Saldana, Lisa | Schaper, Holle | Campbell, Mark | Chamberlain, Patricia | Shapiro, Valerie B. | Kim, B.K. Elizabeth | Fleming, Jennifer L. | LeBuffe, Paul A. | Landes, Sara J. | Lewis, Cara C. | Rodriguez, Allison L. | Marriott, Brigid R. | Comtois, Katherine Anne | Lewis, Cara C. | Stanick, Cameo | Weiner, Bryan J. | Halko, Heather | Dorsey, Caitlin
Implementation Science : IS  2016;11(Suppl 1):85.
Table of contents
Introduction to the 3rd Biennial Conference of the Society for Implementation Research Collaboration: advancing efficient methodologies through team science and community partnerships
Cara Lewis, Doyanne Darnell, Suzanne Kerns, Maria Monroe-DeVita, Sara J. Landes, Aaron R. Lyon, Cameo Stanick, Shannon Dorsey, Jill Locke, Brigid Marriott, Ajeng Puspitasari, Caitlin Dorsey, Karin Hendricks, Andria Pierson, Phil Fizur, Katherine A. Comtois
A1: A behavioral economic perspective on adoption, implementation, and sustainment of evidence-based interventions
Lawrence A. Palinkas
A2: Towards making scale up of evidence-based practices in child welfare systems more efficient and affordable
Patricia Chamberlain
A3: Mixed method examination of strategic leadership for evidence-based practice implementation
Gregory A. Aarons, Amy E. Green, Mark. G. Ehrhart, Elise M. Trott, Cathleen E. Willging
A4: Implementing practice change in Federally Qualified Health Centers: Learning from leaders’ experiences
Maria E. Fernandez, Nicholas H. Woolf, Shuting (Lily) Liang, Natalia I. Heredia, Michelle Kegler, Betsy Risendal, Andrea Dwyer, Vicki Young, Dayna Campbell, Michelle Carvalho, Yvonne Kellar-Guenther
A3: Mixed method examination of strategic leadership for evidence-based practice implementation
Gregory A. Aarons, Amy E. Green, Mark. G. Ehrhart, Elise M. Trott, Cathleen E. Willging
A4: Implementing practice change in Federally Qualified Health Centers: Learning from leaders’ experiences
Maria E. Fernandez, Nicholas H. Woolf, Shuting (Lily) Liang, Natalia I. Heredia, Michelle Kegler, Betsy Risendal, Andrea Dwyer, Vicki Young, Dayna Campbell, Michelle Carvalho, Yvonne Kellar-Guenther
A5: Efficient synthesis: Using qualitative comparative analysis and the Consolidated Framework for Implementation Research across diverse studies
Laura J. Damschroder, Julie C. Lowery
A6: Establishing a veterans engagement group to empower patients and inform Veterans Affairs (VA) health services research
Sarah S. Ono, Kathleen F. Carlson, Erika K. Cottrell, Maya E. O’Neil, Travis L. Lovejoy
A7: Building patient-practitioner partnerships in community oncology settings to implement behavioral interventions for anxious and depressed cancer survivors
Joanna J. Arch, Jill L. Mitchell
A8: Tailoring a Cognitive Behavioral Therapy implementation protocol using mixed methods, conjoint analysis, and implementation teams
Cara C. Lewis, Brigid R. Marriott, Kelli Scott
A9: Wraparound Structured Assessment and Review (WrapSTAR): An efficient, yet comprehensive approach to Wraparound implementation evaluation
Jennifer Schurer Coldiron, Eric J. Bruns, Alyssa N. Hook
A10: Improving the efficiency of standardized patient assessment of clinician fidelity: A comparison of automated actor-based and manual clinician-based ratings
Benjamin C. Graham, Katelin Jordan
A11: Measuring fidelity on the cheap
Rochelle F. Hanson, Angela Moreland, Benjamin E. Saunders, Heidi S. Resnick
A12: Leveraging routine clinical materials to assess fidelity to an evidence-based psychotherapy
Shannon Wiltsey Stirman, Cassidy A. Gutner, Jennifer Gamarra, Dawne Vogt, Michael Suvak, Jennifer Schuster Wachen, Katherine Dondanville, Jeffrey S. Yarvis, Jim Mintz, Alan L. Peterson, Elisa V. Borah, Brett T. Litz, Alma Molino, Stacey Young McCaughanPatricia A. Resick
A13: The video vignette survey: An efficient process for gathering diverse community opinions to inform an intervention
Nancy Pandhi, Nora Jacobson, Neftali Serrano, Armando Hernandez, Elizabeth Zeidler- Schreiter, Natalie Wietfeldt, Zaher Karp
A14: Using integrated administrative data to evaluate implementation of a behavioral health and trauma screening for children and youth in foster care
Michael D. Pullmann, Barbara Lucenko, Bridget Pavelle, Jacqueline A. Uomoto, Andrea Negrete, Molly Cevasco, Suzanne E. U. Kerns
A15: Intermediary organizations as a vehicle to promote efficiency and speed of implementation
Robert P. Franks, Christopher Bory
A16: Applying the Consolidated Framework for Implementation Research constructs directly to qualitative data: The power of implementation science in action
Edward J. Miech, Teresa M. Damush
A17: Efficient and effective scaling-up, screening, brief interventions, and referrals to treatment (SBIRT) training: a snowball implementation model
Jason Satterfield, Derek Satre, Maria Wamsley, Patrick Yuan, Patricia O’Sullivan
A18: Matching models of implementation to system needs and capacities: addressing the human factor
Helen Best, Susan Velasquez
A19: Agency characteristics that facilitate efficient and successful implementation efforts
Miya Barnett, Lauren Brookman-Frazee, Jennifer Regan, Nicole Stadnick, Alison Hamilton, Anna Lau
A20: Rapid assessment process: Application to the Prevention and Early Intervention transformation in Los Angeles County
Jennifer Regan, Alison Hamilton, Nicole Stadnick, Miya Barnett, Anna Lau, Lauren Brookman-Frazee
A21: The development of the Evidence-Based Practice-Concordant Care Assessment: An assessment tool to examine treatment strategies across practices
Nicole Stadnick, Anna Lau, Miya Barnett, Jennifer Regan, Scott Roesch, Lauren Brookman-Frazee
A22: Refining a compilation of discrete implementation strategies and determining their importance and feasibility
Byron J. Powell, Thomas J. Waltz, Matthew J. Chinman, Laura Damschroder, Jeffrey L. Smith, Monica M. Matthieu, Enola K. Proctor, JoAnn E. Kirchner
A23: Structuring complex recommendations: Methods and general findings
Thomas J. Waltz, Byron J. Powell, Matthew J. Chinman, Laura J. Damschroder, Jeffrey L. Smith, Monica J. Matthieu, Enola K. Proctor, JoAnn E. Kirchner
A24: Implementing prolonged exposure for post-traumatic stress disorder in the Department of Veterans Affairs: Expert recommendations from the Expert Recommendations for Implementing Change (ERIC) project
Monica M. Matthieu, Craig S. Rosen, Thomas J. Waltz, Byron J. Powell, Matthew J. Chinman, Laura J. Damschroder, Jeffrey L. Smith, Enola K. Proctor, JoAnn E. Kirchner
A25: When readiness is a luxury: Co-designing a risk assessment and quality assurance process with violence prevention frontline workers in Seattle, WA
Sarah C. Walker, Asia S. Bishop, Mariko Lockhart
A26: Implementation potential of structured recidivism risk assessments with justice- involved veterans: Qualitative perspectives from providers
Allison L. Rodriguez, Luisa Manfredi, Andrea Nevedal, Joel Rosenthal, Daniel M. Blonigen
A27: Developing empirically informed readiness measures for providers and agencies for the Family Check-Up using a mixed methods approach
Anne M. Mauricio, Thomas D. Dishion, Jenna Rudo-Stern, Justin D. Smith
A28: Pebbles, rocks, and boulders: The implementation of a school-based social engagement intervention for children with autism
Jill Locke, Courtney Benjamin Wolk, Colleen Harker, Anne Olsen, Travis Shingledecker, Frances Barg, David Mandell, Rinad S. Beidas
A29: Problem Solving Teletherapy (PST.Net): A stakeholder analysis examining the feasibility and acceptability of teletherapy in community based aging services
Marissa C. Hansen, Maria P. Aranda, Isabel Torres-Vigil
A30: A case of collaborative intervention design eventuating in behavior therapy sustainment and diffusion
Bryan Hartzler
A31: Implementation of suicide risk prevention in an integrated delivery system: Mental health specialty services
Bradley Steinfeld, Tory Gildred, Zandrea Harlin, Fredric Shephard
A32: Implementation team, checklist, evaluation, and feedback (ICED): A step-by-step approach to Dialectical Behavior Therapy program implementation
Matthew S. Ditty, Andrea Doyle, John A. Bickel III, Katharine Cristaudo
A33: The challenges in implementing muliple evidence-based practices in a community mental health setting
Dan Fox, Sonia Combs
A34: Using electronic health record technology to promote and support evidence-based practice assessment and treatment intervention
David H. Lischner
A35: Are existing frameworks adequate for measuring implementation outcomes? Results from a new simulation methodology
Richard A. Van Dorn, Stephen J. Tueller, Jesse M. Hinde, Georgia T. Karuntzos
A36: Taking global local: Evaluating training of Washington State clinicians in a modularized cogntive behavioral therapy approach designed for low-resource settings
Maria Monroe-DeVita, Roselyn Peterson, Doyanne Darnell, Lucy Berliner, Shannon Dorsey, Laura K. Murray
A37: Attitudes toward evidence-based practices across therapeutic orientations
Yevgeny Botanov, Beverly Kikuta, Tianying Chen, Marivi Navarro-Haro, Anthony DuBose, Kathryn E. Korslund, Marsha M. Linehan
A38: Predicting the use of an evidence-based intervention for autism in birth-to-three programs
Colleen M. Harker, Elizabeth A. Karp, Sarah R. Edmunds, Lisa V. Ibañez, Wendy L. Stone
A39: Supervision practices and improved fidelity across evidence-based practices: A literature review
Mimi Choy-Brown
A40: Beyond symptom tracking: clinician perceptions of a hybrid measurement feedback system for monitoring treatment fidelity and client progress
Jack H. Andrews, Benjamin D. Johnides, Estee M. Hausman, Kristin M. Hawley
A41: A guideline decision support tool: From creation to implementation
Beth Prusaczyk, Alex Ramsey, Ana Baumann, Graham Colditz, Enola K. Proctor
A42: Dabblers, bedazzlers, or total makeovers: Clinician modification of a common elements cognitive behavioral therapy approach
Rosemary D. Meza, Shannon Dorsey, Shannon Wiltsey-Stirman, Georganna Sedlar, Leah Lucid
A43: Characterization of context and its role in implementation: The impact of structure, infrastructure, and metastructure
Caitlin Dorsey, Brigid Marriott, Nelson Zounlome, Cara Lewis
A44: Effects of consultation method on implementation of cognitive processing therapy for post-traumatic stress disorder
Cassidy A. Gutner, Candice M. Monson, Norman Shields, Marta Mastlej, Meredith SH Landy, Jeanine Lane, Shannon Wiltsey Stirman
A45: Cross-validation of the Implementation Leadership Scale factor structure in child welfare service organizations
Natalie K. Finn, Elisa M. Torres, Mark. G. Ehrhart, Gregory A. Aarons
A46: Sustainability of integrated smoking cessation care in Veterans Affairs posttraumatic stress disorder clinics: A qualitative analysis of focus group data from learning collaborative participants
Carol A. Malte, Aline Lott, Andrew J. Saxon
A47: Key characteristics of effective mental health trainers: The creation of the Measure of Effective Attributes of Trainers (MEAT)
Meredith Boyd, Kelli Scott, Cara C. Lewis
A48: Coaching to improve teacher implementation of evidence-based practices (EBPs)
Jennifer D. Pierce
A49: Factors influencing the implementation of peer-led health promotion programs targeting seniors: A literature review
Agathe Lorthios-Guilledroit, Lucie Richard, Johanne Filiatrault
A50: Developing treatment fidelity rating systems for psychotherapy research: Recommendations and lessons learned
Kevin Hallgren, Shirley Crotwell, Rosa Muñoz, Becky Gius, Benjamin Ladd, Barbara McCrady, Elizabeth Epstein
A51: Rapid translation of alcohol prevention science
John D. Clapp, Danielle E. Ruderman
A52: Factors implicated in successful implementation: evidence to inform improved implementation from high and low-income countries
Melanie Barwick, Raluca Barac, Stanley Zlotkin, Laila Salim, Marnie
Davidson
A53: Tracking implementation strategies prospectively: A practical approach
Alicia C. Bunger, Byron J. Powell, Hillary A. Robertson
A54: Trained but not implementing: the need for effective implementation planning tools
Christopher Botsko
A55: Evidence, context, and facilitation variables related to implementation of Dialectical Behavior Therapy: Qualitative results from a mixed methods inquiry in the Department of Veterans Affairs
Sara J. Landes, Brandy N. Smith, Allison L. Rodriguez, Lindsay R. Trent, Monica M. Matthieu
A56: Learning from implementation as usual in children’s mental health
Byron J. Powell, Enola K. Proctor
A57: Rates and predictors of implementation after Dialectical Behavior Therapy Intensive Training
Melanie S. Harned, Marivi Navarro-Haro, Kathryn E. Korslund, Tianying Chen, Anthony DuBose, André Ivanoff, Marsha M. Linehan
A58: Socio-contextual determinants of research evidence use in public-youth systems of care
Antonio R. Garcia, Minseop Kim, Lawrence A. Palinkas, Lonnie Snowden, John Landsverk
A59: Community resource mapping to integrate evidence-based depression treatment in primary care in Brazil: A pilot project
Annika C. Sweetland, Maria Jose Fernandes, Edilson Santos, Cristiane Duarte, Afrânio Kritski, Noa Krawczyk, Caitlin Nelligan, Milton L. Wainberg
A60: The use of concept mapping to efficiently identify determinants of implementation in the National Institute of Health--President’s Emergent Plan for AIDS Relief Prevention of Mother to Child HIV Transmission Implementation Science Alliance
Gregory A. Aarons, David H. Sommerfeld, Benjamin Chi, Echezona Ezeanolue, Rachel Sturke, Lydia Kline, Laura Guay, George Siberry
A61: Longitudinal remote consultation for implementing collaborative care for depression
Ian M. Bennett, Rinad Beidas, Rachel Gold, Johnny Mao, Diane Powers, Mindy Vredevoogd, Jurgen Unutzer
A62: Integrating a peer coach model to support program implementation and ensure long- term sustainability of the Incredible Years in community-based settings
Jennifer Schroeder, Lane Volpe, Julie Steffen
A63: Efficient sustainability: Existing community based supervisors as evidence-based treatment supports
Shannon Dorsey, Michael D Pullmann, Suzanne E. U. Kerns, Nathaniel Jungbluth, Lucy Berliner, Kelly Thompson, Eliza Segell
A64: Establishment of a national practice-based implementation network to accelerate adoption of evidence-based and best practices
Pearl McGee-Vincent, Nancy Liu, Robyn Walser, Jennifer Runnals, R. Keith Shaw, Sara J. Landes, Craig Rosen, Janet Schmidt, Patrick Calhoun
A65: Facilitation as a mechanism of implementation in a practice-based implementation network: Improving care in a Department of Veterans Affairs post-traumatic stress disorder outpatient clinic
Ruth L. Varkovitzky, Sara J. Landes
A66: The ACT SMART Toolkit: An implementation strategy for community-based organizations providing services to children with autism spectrum disorder
Amy Drahota, Jonathan I. Martinez, Brigitte Brikho, Rosemary Meza, Aubyn C. Stahmer, Gregory A. Aarons
A67: Supporting Policy In Health with Research: An intervention trial (SPIRIT) - protocol and early findings
Anna Williamson
A68: From evidence based practice initiatives to infrastructure: Lessons learned from a public behavioral health system’s efforts to promote evidence based practices
Ronnie M. Rubin, Byron J. Powell, Matthew O. Hurford, Shawna L. Weaver, Rinad S. Beidas, David S. Mandell, Arthur C. Evans
A69: Applying the policy ecology model to Philadelphia’s behavioral health transformation efforts
Byron J. Powell, Rinad S. Beidas, Ronnie M. Rubin, Rebecca E. Stewart, Courtney Benjamin Wolk, Samantha L. Matlin, Shawna Weaver, Matthew O. Hurford, Arthur C. Evans, Trevor R. Hadley, David S. Mandell
A70: A model for providing methodological expertise to advance dissemination and implementation of health discoveries in Clinical and Translational Science Award institutions
Donald R. Gerke, Beth Prusaczyk, Ana Baumann, Ericka M. Lewis, Enola K. Proctor
A71: Establishing a research agenda for the Triple P Implementation Framework
Jenna McWilliam, Jacquie Brown, Michelle Tucker
A72: Cheap and fast, but what is “best?”: Examining implementation outcomes across sites in a state-wide scaled-up evidence-based walking program, Walk With Ease
Kathleen P Conte
A73: Measurement feedback systems in mental health: Initial review of capabilities and characteristics
Aaron R. Lyon, Meredith Boyd, Abigail Melvin, Cara C. Lewis, Freda Liu, Nathaniel Jungbluth
A74: A qualitative investigation of case managers’ attitudes toward implementation of a measurement feedback system in a public mental health system for youth
Amelia Kotte, Kaitlin A. Hill, Albert C. Mah, Priya A. Korathu-Larson, Janelle R. Au, Sonia Izmirian, Scott Keir, Brad J. Nakamura, Charmaine K. Higa-McMillan
A75: Multiple pathways to sustainability: Using Qualitative Comparative Analysis to uncover the necessary and sufficient conditions for successful community-based implementation
Brittany Rhoades Cooper, Angie Funaiole, Eleanor Dizon
A76: Prescribers’ perspectives on opioids and benzodiazepines and medication alerts to reduce co-prescribing of these medications
Eric J. Hawkins, Carol A. Malte, Hildi J. Hagedorn, Douglas Berger, Anissa Frank, Aline Lott, Carol E. Achtmeyer, Anthony J. Mariano, Andrew J. Saxon
A77: Adaptation of Coordinated Anxiety Learning and Management for comorbid anxiety and substance use disorders: Delivery of evidence-based treatment for anxiety in addictions treatment centers
Kate Wolitzky-Taylor, Richard Rawson, Richard Ries, Peter Roy-Byrne, Michelle Craske
A78: Opportunities and challenges of measuring program implementation with online surveys
Dena Simmons, Catalina Torrente, Lori Nathanson, Grace Carroll
A79: Observational assessment of fidelity to a family-centered prevention program: Effectiveness and efficiency
Justin D. Smith, Kimbree Brown, Karina Ramos, Nicole Thornton, Thomas J. Dishion, Elizabeth A. Stormshak, Daniel S. Shaw, Melvin N. Wilson
A80: Strategies and challenges in housing first fidelity: A multistate qualitative analysis
Mimi Choy-Brown, Emmy Tiderington, Bikki Tran Smith, Deborah K. Padgett
A81: Procurement and contracting as an implementation strategy: Getting To Outcomes® contracting
Ronnie M. Rubin, Marilyn L. Ray, Abraham Wandersman, Andrea Lamont, Gordon Hannah, Kassandra A. Alia, Matthew O. Hurford, Arthur C. Evans
A82: Web-based feedback to aid successful implementation: The interactive Stages of Implementation Completion (SIC)TM tool
Lisa Saldana, Holle Schaper, Mark Campbell, Patricia Chamberlain
A83: Efficient methodologies for monitoring fidelity in routine implementation: Lessons from the Allentown Social Emotional Learning Initiative
Valerie B. Shapiro, B.K. Elizabeth Kim, Jennifer L. Fleming, Paul A. LeBuffe
A84: The Society for Implementation Research Collaboration (SIRC) implementation development workshop: Results from a new methodology for enhancing implementation science proposals
Sara J. Landes, Cara C. Lewis, Allison L. Rodriguez, Brigid R. Marriott, Katherine Anne Comtois
A85: An update on the Society for Implementation Research Collaboration (SIRC) Instrument Review Project
doi:10.1186/s13012-016-0428-0
PMCID: PMC4928139  PMID: 27357964
13.  The role of the African-American physician in reducing traffic-related injury and death among African Americans: consensus report of the National Medical Association. 
ISSUE: Traffic-related injuries and fatalities disproportionately affect the African American community. These high rates of traffic-related death and injury among African Americans manifest in multiple areas of traffic safety, including: Failure to use seat belts and child restraints. High incidence of alcohol-impaired driving. Failure to follow child passenger and seat belt safety laws and recommendations. High rates of pedestrian accidents, ofen brought on by impairments of drivers and/or pedestrians. Research indicates that national public information campaigns, with general messages only slightly modified for African American audiences, have not been culturally appropriate or effective in changing traffic safety behavior. In addition, traditional distribution mechanisms for these messages have not effectively reached the target population. Evidence suggests that in the African American community, there is a pervasive lack of knowledge of the devastating impact of traffic-related accidents on the overall health status of the community. This lack of information has resulted in a tragic cycle, in which parents fail to model safe operation of motor vehicles, and generation after generation copy this behavior, increasing the community's vulnerability to serious injuries and untimely deaths. This trend toward improper traffic safety habits among African Americans persists despite federal, state and local laws to enforce and promote sound traffic safety practices. OBJECTIVE: To study the existence of disparities in traffic-related injury and death among African Americans and to determine what kinds of traffic safety messages and campaigns will be effective in encouraging African Americans to respond to safety laws in sufficient numbers to reduce the disproportionately high rate of injury and death. Traffic safety issues were examined to effectively recommend policy, address barriers, best practices, and intervention strategies for the National Medical Association, its physician members, their patients, and their communities. CONSENSUS PROCESS: A literature review, driven by research instruments from numerous organizations included reports and materials from the National Highway Traffic Safety Administration (NHTSA), American Academy of Pediatrics, National Committee for Injury Prevention and Control, U.S. Centers for Disease Control and Prevention (CDC), Mothers Against Drunk Driving (MADD), and the National SAFE KIDS Campaign. Both the Meharry Medical College report, Achieving a Credible Health and Safety Approach to Increasing Seat Belt Use Among African-Americans, and the U.S. Department of Transportation's Blue Ribbon Panel to Increase Seat Belt Use Among African Americans: A Report to the Nation, provided substantial background for the panel. More than 60 pieces of traffic safety literature have been examined to date. Based on the literature review, a short list of the most relevant issues affecting African Americans and traffic safety was devised. It includes: The disproportionately high rate of traffic-related injury and death among African Americans. The cost in health, monetary costs and other associated costs of traffic safety accidents and injuries. The number of traffic-related injuries and deaths that could be prevented if more African Americans observed good traffic safety practices. Barriers to practicing good traffic safety habits among African Americans. Failure of laws and public information campaigns to influence improved traffic safety practices among African Americans sufficient to reduce disparities in traffic-related injury and death. In July 2001, NMA convened a consensus panel of experts in St. Thomas, U.S. Virgin Islands, to review a briefing document summarizing the most salient traffic safety issues among African Americans. The panel elaborated on key issues, including existing policy and standards for the use of child restraint devices to secure infants and toddlers, existing data regarding disparities in traffic-related injury and death among African Americans, and the cultural, age and developmental appropriateness of existing safety campaigns. SUMMARY: Public information campaigns have successfully improved traffic safety practices among the general public but in large part have been unsuccessful among minority populations-including African Americans. This may be due to: A failure to use techniques and messages that are culturally sensitive to African Americans. Campaigns that have targeted geographic and social centers where African Americans are not broadly present. Lack of awareness of the disproportionate effect motor vehicle crashes are having on African Americans. Scientifically based, culturally appropriate intervention strategies need to be devised and implemented by African American institutions and organizations to improve traffic safety practices and reduce the high rate of traffic-related injury and deaths among African Americans.
PMCID: PMC2594128  PMID: 11858225
14.  Relationship between Vehicle Emissions Laws and Incidence of Suicide by Motor Vehicle Exhaust Gas in Australia, 2001–06: An Ecological Analysis 
PLoS Medicine  2010;7(1):e1000210.
In an ecological study, David Studdert and colleagues show that areas of Australia with fewer vehicles pre-dating stringent carbon monoxide emission laws have lower rates of suicide due to asphyxiation by motor vehicle exhaust gas.
Background
Globally, suicide accounts for 5.2% of deaths among persons aged 15 to 44 years and its incidence is rising. In Australia, suicide rates peaked in 1997 and have been declining since. A substantial part of that decline stems from a plunge in suicides by one particular method: asphyxiation by motor vehicle exhaust gas (MVEG). Although MVEG remains the second most common method of suicide in Australia, its incidence decreased by nearly 70% in the decade to 2006. The extent to which this phenomenon has been driven by national laws in 1986 and 1999 that lowered permissible levels of carbon monoxide (CO) emissions is unknown. The objective of this ecological study was to test the relationship by investigating whether areas of Australia with fewer noxious vehicles per capita experienced lower rates of MVEG suicide.
Methods and Findings
We merged data on MVEG suicides in Australia (2001–06) with data on the number and age of vehicles in the national fleet, as well as socio-demographic data from the national census. Poisson regression was used to analyse the relationship between the incidence of suicide within two levels of geographical area—postcodes and statistical subdivisions (SSDs)—and the population density of pre-1986 and pre-1999 passenger vehicles in those areas. (There was a mean population of 8,302 persons per postcode in the study dataset and 87,413 persons per SSD.) The annual incidence of MVEG suicides nationwide decreased by 57% (from 2.6 per 100,000 in 2001 to 1.1 in 2006) during the study period; the population density of pre-1986 and pre-1999 vehicles decreased by 55% (from 14.2 per 100 persons in 2001 to 6.4 in 2006) and 26% (from 44.5 per 100 persons in 2001 to 32.9 in 2006), respectively. Area-level regression analysis showed that the suicide rates were significantly and positively correlated with the presence of older vehicles. A percentage point decrease in the population density of pre-1986 vehicles was associated with a 6% decrease (rate ratio [RR] = 1.06; 95% confidence interval [CI] 1.05–1.08) in the incidence of MVEG suicide within postcode areas; a percentage point decrease in the population density of pre-1999 vehicles was associated with a 3% decrease (RR = 1.03; 95% CI 1.02–1.04) in the incidence of MVEG suicide.
Conclusions
Areas of Australia with fewer vehicles predating stringent CO emission laws experience lower rates of MVEG suicide. Although those emission laws were introduced primarily for environmental reasons, countries that lack them may miss the benefits of a serendipitous suicide prevention strategy.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Suicide (self-inflicted death) is a major, preventable public-health problem. About 1 million people die each year from suicide and about 20 times as many people attempt suicide. Globally, suicide rates have increased by nearly a half over the past 45 years and suicide is now among the three leading causes of death in people aged 15–44 years. Within this age group, 1 in 20 deaths is a suicide. Most people who commit suicide have a mental illness, usually depression or substance abuse, but suicide can also be triggered by a stressful event such as losing a partner. Often warning signs are present—a person who talks about killing themselves must always be taken seriously. Adequate prevention and treatment of mental illness and interventions that teach young people coping skills and improve their self-esteem have shown promise in reducing suicide rates, as have strategies (for example, restrictions on the sale of pain killers) that reduce access to common methods of suicide.
Why Was This Study Done?
In Australia, the suicide rate has been declining since 1997 when a record 2,722 suicides occurred. Fewer suicides by asphyxiation (oxygen deprivation) by motor vehicle gas exhaust (MVEG) account for much of this decline. MVEG contains carbon monoxide, a toxic gas that blocks oxygen transport around the body. Although MVEG suicide is still the second most common means of suicide in Australia, its incidence has dropped by two-thirds since 1997 but why? One possibility is that national laws passed in 1986 and 1999 that lowered the permissible level of carbon monoxide in vehicle exhaust for environmental reasons have driven the decline in MVEG suicides. Evidence from other countries suggests that this might be the case but no-one has directly investigated the relationship between MVEG suicide and the use of vehicles with reduced carbon monoxide emissions. In this ecological study (a study in which the effect of an intervention is studied on groups of people rather than on individuals), the researchers ask whether the number of pre-1986 and pre-1999 vehicles within particular geographic areas in Australia is correlated with the rates of MVEG suicide in those areas between 2001 and 2006.
What Did the Researchers Do and Find?
The researchers obtained data on MVEG suicides from the Australian National Coroners Information System and data on the number and age of vehicles on the road from the Australian Bureau of Statistics. MVEG suicides dropped from 498 in 2001 to 231 in 2006, they report, and 28% of passenger vehicles registered in Australia were made before 1986 in 2001 but only 12% in 2006; the percentage of registered vehicles made before 1999 fell from 89% to 60% over the same period. The researchers then used a statistical technique called Poisson regression to analyze the relationship within postcode areas between the incidence of MVEG suicide and the presence of pre-1986 and pre-1999 vehicles. This analysis showed that in areas where older vehicles were more numerous there were more MVEG suicides (a positive correlation). Specifically, the researchers calculate that if the proportion of pre-1986 vehicles on the road in Australia had stayed at 2001 levels throughout their study period, 621 extra MVEG suicides would have occurred in the country over that time.
What Do These Findings Mean?
These findings show that in areas of Australia that had fewer vehicles on the road predating stringent vehicle emission laws, there were lower rates of MVEG suicide between 2001 and 2006. Unfortunately, this study cannot provide any information on the actual age of vehicles used in MVEG suicides or on the relationship between vehicle age and attempted MVEG suicides. It also cannot reveal whether those areas that had the sharpest decreases in the density of older vehicles had the sharpest decreases in suicide rates because very few suicides occurred in most postcodes during the study. Most importantly, the design of this study means that the researchers cannot discount the possibility that the changes in Australia's emission laws have steered people towards other methods of taking their own lives. Nevertheless, the findings of this study suggest that the introduction of stringent vehicle emission laws for environmental reasons might, serendipitously, be a worthwhile long-term suicide prevention strategy in countries where MVEG suicide is common.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000210.
Another PLoS Medicine research article, by Shu-Sen Chang and colleagues, investigates the evolution of the epidemic of charcoal-burning suicide in Taiwan
The US National Institute of Mental Health provides information on suicide and suicide prevention
The UK National Health Service Choices Web site has detailed information about suicide and its prevention
The World Health Organization provides information on the global burden of suicide and on suicide prevention (in several languages)
MedlinePlus provides links to further resources about suicide (in English and Spanish)
Suicide Prevention Australia is a nonprofit, nongovernmental organization working as a public-health advocate in suicide prevention
The Australian Institute of Health and Welfare has recently published a review of suicide statistics in Australia
The National Coroners Information System is a database contains information on every death reported to an Australian coroner since July 2000 (January 2001 for Queensland)
doi:10.1371/journal.pmed.1000210
PMCID: PMC2796388  PMID: 20052278
15.  Do sexual health campaigns work? An outcome evaluation of a media campaign to increase chlamydia testing among young people aged 15–24 in England 
BMC Public Health  2013;13:484.
Background
A national multimedia campaign was launched in January 2010, to increase the proportion of young people tested for chlamydia. This study aimed to evaluate the impact of the campaign on the coverage and positivity within the National Chlamydia Screening Programme (NSCP) in England.
Method
An interrupted time series of anonymised NCSP testing reports for England for a 27 month period (1st April 2008 to 30th June 2010) was analysed. Reports were assigned to a pre-campaign, campaign and post campaign phase according to the test date. Exclusion criteria included tests for clinical reasons, contacts of known cases, and tests returned from prisons or military services.
Negative binomial and logistic regression modelling was used to provide an estimate for the change in coverage and positivity, during, and after the campaign and estimates were adjusted for secular and cyclical trends.
Results
Adjusting for cyclical and secular trends, there was no change in the overall testing coverage either during (RR: 0.91; 95% CI: 0.72-1.14) or after (RR: 0.88; 95%CI: 0.69-1.11) the campaign. The coverage varied amongst different socio-demographic groups, testing of men increased during the campaign phase while testing of people of black and other ethnic groups fell in this phase. The positivity rate was increased during the campaign (OR: 1.18; 95% CI 1.13-1.23) and further increased in the post-campaign phase (OR: 1.40; 95% CI 1.30-1.51). The proportion of chlamydia infections detected increased for all socio-demographic and self-reported sexual behaviour groups both during and after the campaign.
Conclusion
The uptake of chlamydia testing rose during the campaign; however, this apparent increase was not maintained once overall trends in testing were taken into account. Nonetheless, once secular and cyclical trends were controlled for, the campaign was associated with an increased positivity linked to increased testing of high risk individuals groups in the target population who were previously less likely to come forward for testing. However, our study indicated that there may have been a disparity in the impact of the campaign on different population groups. The content and delivery of ongoing and future information campaigns aimed at increasing chlamydia screening should be carefully developed so that they are relevant to all sections of the target population.
doi:10.1186/1471-2458-13-484
PMCID: PMC3671151  PMID: 23683345
Chlamydia screening; Mass media campaign; Multi media campaigns
16.  Effectiveness of Telephone-Based Health Coaching for Patients with Chronic Conditions: A Randomised Controlled Trial 
PLoS ONE  2016;11(9):e0161269.
Background
Chronic diseases, like diabetes mellitus, heart disease and cancer are leading causes of death and disability. These conditions are at least partially preventable or modifiable, e.g. by enhancing patients’ self-management. We aimed to examine the effectiveness of telephone-based health coaching (TBHC) in chronically ill patients.
Methods and Findings
This prospective, pragmatic randomized controlled trial compares an intervention group (IG) of participants in TBHC to a control group (CG) without TBHC. Endpoints were assessed two years after enrolment. Three different groups of insurees with 1) multiple conditions (chronic campaign), 2) heart failure (heart failure campaign), or 3) chronic mental illness conditions (mental health campaign) were targeted. The telephone coaching included evidence-based information and was based on the concepts of motivational interviewing, shared decision-making, and collaborative goal setting. Patients received an average of 12.9 calls. Primary outcome was time from enrolment until hospital readmission within a two-year follow-up period. Secondary outcomes comprised the probability of hospital readmission, number of daily defined medication doses (DDD), frequency and duration of inability to work, and mortality within two years. All outcomes were collected from routine data provided by the statutory health insurance. As informed consent was obtained after randomization, propensity score matching (PSM) was used to minimize selection bias introduced by decliners. For the analysis of hospital readmission and mortality, we calculated Kaplan-Meier curves and estimated hazard ratios (HR). Probability of hospital readmission and probability of death were analysed by calculating odds ratios (OR). Quantity of health service use and inability to work were analysed by linear random effects regression models. PSM resulted in patient samples of 5,309 (IG: 2,713; CG: 2,596) in the chronic campaign, of 660 (IG: 338; CG: 322) in the heart failure campaign, and of 239 (IG: 101; KG: 138) in the mental health campaign. In none of the three campaigns, there were significant differences between IG and CG in time until hospital readmission. In the chronic campaign, the probability of hospital readmission was higher in the IG than in the CG (OR = 1.13; p = 0.045); no significant differences could be found for the other two campaigns. In the heart failure campaign, the IG showed a significantly reduced number of hospital admissions (-0.41; p = 0.012), although the corresponding reduction in the number of hospital days was not significant. In the chronic campaign, the IG showed significantly increased number of DDDs. Most striking, there were significant differences in mortality between IG and CG in the chronic campaign (OR = 0.64; p = 0.005) as well as in the heart failure campaign (OR = 0.44; p = 0.001).
Conclusions
While TBHC seems to reduce hospitalization only in specific patient groups, it may reduce mortality in patients with chronic somatic conditions. Further research should examine intervention effects in various subgroups of patients, for example for different diagnostic groups within the chronic campaign, or duration of coaching.
Trial Registration
German Clinical Trials Register DRKS00000584
doi:10.1371/journal.pone.0161269
PMCID: PMC5025178  PMID: 27632360
17.  IMPACT OF THE “GIVING CIGARETTES IS GIVING HARM” CAMPAIGN ON KNOWLEDGE AND ATTITUDES OF CHINESE SMOKERS 
Tobacco control  2014;24(0 4):iv28-iv34.
Objective
To date there is limited published evidence on the efficacy of tobacco control mass media campaigns in China. This study aimed to evaluate the impact of a mass media campaign “Giving Cigarettes is Giving Harm” (GCGH) on Chinese smokers’ knowledge of smoking-related harms and attitudes toward cigarette gifts.
Methods
Population-based, representative data were analyzed from a longitudinal cohort of 3,709 adult smokers who participated in the International Tobacco Control China Survey conducted in six Chinese cities before and after the campaign. Logistic regression models were estimated to examine associations between campaign exposure and attitudes about cigarettes as gifts measured post-campaign. Poisson regression models were estimated to assess the effects of campaign exposure on post-campaign knowledge, adjusting for pre-campaign knowledge.
Findings
Fourteen percent (n=335) of participants recalled the campaign within the cities where the GCGH campaign was implemented. Participants in the intervention cities who recalled the campaign were more likely to disagree that cigarettes are good gifts (71% vs. 58%, p<0.01) and had greater levels of campaign-targeted knowledge than those who did not recall the campaign (Mean=1.97 vs. 1.62, p<0.01). Disagreeing that cigarettes are good gifts was higher in intervention cities than in control cities. Changes in campaign-targeted knowledge were similar in both cities, perhaps due to a secular trend, low campaign recall, or contamination issues.
Conclusions
These findings suggest that the GCGH campaign increased knowledge of smoking harms, which could promote downstream cessation. Findings provide evidence to support future campaign development to effectively fight the tobacco epidemic in China.
doi:10.1136/tobaccocontrol-2013-051475
PMCID: PMC4580527  PMID: 24813427
Low/Middle income country; Media; Social marketing; Prevention; Tobacco control campaign evaluation
18.  Exploring the role of communications in quality improvement: A case study of the 1000 Lives Campaign in NHS Wales 
Introduction
Effective communication is critical to successful large-scale change. Yet, in our experience, communications strategies are not formally incorporated into quality improvement (QI) frameworks. The 1000 Lives Campaign (‘Campaign’) was a large-scale national QI collaborative that aimed to save an additional 1000 lives and prevent 50 000 episodes of harm in Welsh health care over a 2-year period. We use the Campaign as a case study to describe the development, application, and impact of a communications strategy embedded in a large-scale QI initiative.
Methods
A comprehensive communications strategy guided communications work during the Campaign. The main aims of the communications strategy were to engage the hearts and minds of frontline National Health Service (NHS) staff in the Campaign and promote their awareness and understanding of specific QI interventions and the wider patient safety agenda. We used qualitative and quantitative measures to monitor communications outputs and assess how the communications strategy influenced awareness and knowledge of frontline NHS staff.
Results
The communications strategy facilitated clear and consistent framing of Campaign messages and allowed dissemination of information related to the range of QI interventions. It reaffirmed the aim and value of the Campaign to frontline staff, thereby promoting sustained engagement with Campaign activities. The communications strategy also built the profile of the Campaign both internally with NHS organizations across Wales and externally with the media, and played a pivotal role in improving awareness and understanding of the patient safety agenda. Ultimately, outcomes from the communications strategy could not be separated from overall Campaign outcomes.
Conclusion and recommendations
Systematic and structured communications can support and enhance QI initiatives. From our experience, we developed a ‘communications bundle’ consisting of six core components. We recommend that communications bundles be incorporated into existing QI methodology, though details should be tailored to the specific context and available resource.
doi:10.1179/1753807615Y.0000000006
PMCID: PMC4391293  PMID: 25878725
Communications strategy; Evaluation; Patient safety; Quality improvement; Safety culture; Wales
19.  Calls for help after september 11: a community mental health hot line 
Although unprepared for a disaster of the magnitude of September 11th, New York City's mental health system responded immediately. Within weeks, Project Liberty, a recovery program funded by the Federal Emergency Management Agency (FEMA), was in operation. The program provided free education, outreach, and crisis counseling services for those affected by the disaster and its aftermath. LifeNet, a 24-bour, 7-day-a-week mental health information and referral botline, is a key component of Project Liberty. In this article, we describe the operation of LifeNet and examine the volume of calls to the hotline during the 6 months following the terrorist attacks on the World Trade Center. We describe the demographics of the callers and the kinds of disaster-related mental bealth problems that callers presented. The data indicate a clear pattern of increasing calls from October through March for all demographic subgroups except seniors. Callers complaining of symptoms of posttraumatic stress and symptoms of anxiety, panic, and phobia increased over time. Bereavement-related calls increased as well. The number of callers who reported symptoms of depression and substance abuse/dependence did not show as clear-cut an increase over time. We looked at the volume of LifeNet calls in relation to the Project Liberty media campaign and suggest that the campaign bas had a positive effect on call volume and that its impact is likely to continue over time.
doi:10.1093/jurban/79.3.417
PMCID: PMC3456795  PMID: 12200512
20.  Cost-Effectiveness of Interventions to Promote Physical Activity: A Modelling Study 
PLoS Medicine  2009;6(7):e1000110.
Linda Cobiac and colleagues model the costs and health outcomes associated with interventions to improve physical activity in the population, and identify specific interventions that are likely to be cost-saving.
Background
Physical inactivity is a key risk factor for chronic disease, but a growing number of people are not achieving the recommended levels of physical activity necessary for good health. Australians are no exception; despite Australia's image as a sporting nation, with success at the elite level, the majority of Australians do not get enough physical activity. There are many options for intervention, from individually tailored advice, such as counselling from a general practitioner, to population-wide approaches, such as mass media campaigns, but the most cost-effective mix of interventions is unknown. In this study we evaluate the cost-effectiveness of interventions to promote physical activity.
Methods and Findings
From evidence of intervention efficacy in the physical activity literature and evaluation of the health sector costs of intervention and disease treatment, we model the cost impacts and health outcomes of six physical activity interventions, over the lifetime of the Australian population. We then determine cost-effectiveness of each intervention against current practice for physical activity intervention in Australia and derive the optimal pathway for implementation. Based on current evidence of intervention effectiveness, the intervention programs that encourage use of pedometers (Dominant) and mass media-based community campaigns (Dominant) are the most cost-effective strategies to implement and are very likely to be cost-saving. The internet-based intervention program (AUS$3,000/DALY), the GP physical activity prescription program (AUS$12,000/DALY), and the program to encourage more active transport (AUS$20,000/DALY), although less likely to be cost-saving, have a high probability of being under a AUS$50,000 per DALY threshold. GP referral to an exercise physiologist (AUS$79,000/DALY) is the least cost-effective option if high time and travel costs for patients in screening and consulting an exercise physiologist are considered.
Conclusions
Intervention to promote physical activity is recommended as a public health measure. Despite substantial variability in the quantity and quality of evidence on intervention effectiveness, and uncertainty about the long-term sustainability of behavioural changes, it is highly likely that as a package, all six interventions could lead to substantial improvement in population health at a cost saving to the health sector.
Please see later in the article for Editors' Summary
Editors' Summary
Background
The human body needs regular physical activity throughout life to stay healthy. Physical activity—any bodily movement produced by skeletal muscles that uses energy—helps to maintain a healthy body weight and to prevent or delay heart disease, stroke, type 2 diabetes, colon cancer, and breast cancer. In addition, physically active people feel better and live longer than physically inactive people. For an adult, 30 minutes of moderate physical activity—walking briskly, gardening, swimming, or cycling—at least five times a week is sufficient to promote and maintain health. But at least 60% of the world's population does not do even this modest amount of physical activity. The daily lives of people in both developed and developing countries are becoming increasingly sedentary. People are sitting at desks all day instead of doing manual labor; they are driving to work in cars instead of walking or cycling; and they are participating less in physical activities during their leisure time.
Why Was This Study Done?
In many countries, the chronic diseases that are associated with physical inactivity are now a major public-health problem; globally, physical inactivity causes 1.9 million deaths per year. Clearly, something has to be done about this situation. Luckily, there is no shortage of interventions designed to promote physical activity, ranging from individual counseling from general practitioners to mass-media campaigns. But which intervention or package of interventions will produce the optimal population health benefits relative to cost? Although some studies have examined the cost-effectiveness of individual interventions, different settings for analysis and use of different methods and assumptions make it difficult to compare results and identify which intervention approaches should be give priority by policy makers. Furthermore, little is known about the cost-effectiveness of packages of interventions. In this study, the researchers investigate the cost-effectiveness in Australia (where physical inactivity contributes to 10% of deaths) of a package of interventions designed to promote physical activity in adults using a standardized approach (ACE-Prevention) to the assessment of the cost-effectiveness of health-care interventions.
What Did the Researchers Do and Find?
The researchers selected six interventions for their study: general practitioner “prescription” of physical activity; general practitioner referral to an exercise physiologist; a mass-media campaign to promote physical activity; the TravelSmart car use reduction program; a campaign to encourage the use of pedometers to increase physical activity; and an internet-based program. Using published data on the effects of physical activity on the amount of illness and death caused by breast and colon cancer, heart disease, stroke, and type 2 diabetes and on the effectiveness of each intervention, the researchers calculated the health outcomes of each intervention in disability-adjusted life years (DALY; a year of healthy life lost because of premature death or disability) averted over the lifetime of the Australian population. They also calculated the costs associated with each intervention offset by the costs associated with the five conditions listed above. These analyses showed that the pedometer program and the mass-media campaign were likely to be the most cost-effective interventions. These interventions were also most likely to be cost-saving. Referral to an exercise physiologist was the least cost-effective intervention. The other three interventions, though unlikely to be cost-saving, were likely to be cost-effective. Finally, a package of all six interventions would be cost-effective and would avert 61,000 DALYs, a third of what could be achieved if every Australian did 30 minutes of physical activity five times a week.
What Do These Findings Mean?
As in all modeling studies, these findings depend on the quality of the data and on the assumptions included by the researchers in their calculations. Unfortunately, there was substantial variability in the quantity and quality of evidence on the effectiveness of each intervention and uncertainty about the long-term effects of each intervention. Nevertheless, the findings presented in this study suggest that the assessment of the cost-effectiveness of a combination of interventions designed to promote physical activity might provide policy makers with some guidance about the best way to reduce the burden of disease caused by physical inactivity. More specifically, for Australia, these findings suggest that the package of the six interventions considered here is likely to provide a cost-effective way to substantially improve the health of the nation.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000110.
The World Health Organization provides information about physical activity and health (in several languages); it also provides an explanation of DALYs
The US Centers for Disease Control and Prevention provides information on physical activity for different age groups and for health professionals
The UK National Health Service information source Choices also explains the benefits of regular physical activity
MedlinePlus has links to other resources about exercise and physical fitness (in English and Spanish)
The University of Queensland Web site has more information on ACE-Prevention (Assessing Cost-Effectiveness Prevention)
doi:10.1371/journal.pmed.1000110
PMCID: PMC2700960  PMID: 19597537
21.  "Getting the lead out" in Hartford, Connecticut: a multifaceted lead-poisoning awareness campaign. 
As part of a citywide effort to increase lead poisoning awareness within the city of Hartford, Connecticut, the Hartford Health Department implemented a multifaceted public health campaign involving several novel elements and partnerships, including the use of municipal sanitation trucks to disseminate lead-poisoning prevention messages throughout the city. To evaluate campaign reach and effectiveness, Health Department personnel collected measures of lead-poisoning knowledge, recall of campaign components, and reports of steps taken to prevent lead poisoning from 180 largely ethnic minority parents of preschool-age children. Key results were as follows: a) Recall of campaign components ranged from 21.5 to 62.6%, with newspaper advertisements and signs on buses and billboards recalled most often and a video broadcast on public-access television recalled least often. b) More than 45% of respondents reported that they took steps to prevent lead poisoning because of at least one of the campaign components, with the newspaper advertisements being the most effective component in terms of prompting lead-poisoning prevention behavior. c) Respondents' awareness was particularly low in terms of how medical personnel and procedures can and cannot detect and prevent lead poisoning in children. This campaign prompted caregivers to take steps to prevent lead poisoning and may help public health professionals in other communities to develop novel ideas through which to embark on similar initiatives.
PMCID: PMC1241788  PMID: 14698922
22.  The Evolution of the Epidemic of Charcoal-Burning Suicide in Taiwan: A Spatial and Temporal Analysis 
PLoS Medicine  2010;7(1):e1000212.
Shu-Sen Chang and colleagues describe the epidemiology of an epidemic of suicide by charcoal burning in Taiwan and discuss possible reasons for its spread.
Background
An epidemic of carbon monoxide poisoning suicide by burning barbecue charcoal has occurred in East Asia in the last decade. We investigated the spatial and temporal evolution of the epidemic to assess its impact on the epidemiology of suicide in Taiwan.
Methods and Findings
Age-standardised rates of suicide and undetermined death by charcoal burning were mapped across townships (median population aged 15 y or over = 27,000) in Taiwan for the periods 1999–2001, 2002–2004, and 2005–2007. Smoothed standardised mortality ratios of charcoal-burning and non-charcoal-burning suicide and undetermined death across townships were estimated using Bayesian hierarchical models. Trends in overall and method-specific rates were compared between urban and rural areas for the period 1991–2007. The epidemic of charcoal-burning suicide in Taiwan emerged more prominently in urban than rural areas, without a single point of origin, and rates of charcoal-burning suicide remained highest in the metropolitan regions throughout the epidemic. The rural excess in overall suicide rates prior to 1998 diminished as rates of charcoal-burning suicide increased to a greater extent in urban than rural areas.
Conclusions
The charcoal-burning epidemic has altered the geography of suicide in Taiwan. The observed pattern and its changes in the past decade suggest that widespread media coverage of this suicide method and easy access to barbecue charcoal may have contributed to the epidemic. Prevention strategies targeted at these factors, such as introducing and enforcing guidelines on media reporting and restricting access to charcoal, may help tackle the increase of charcoal-burning suicides.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, about a million people take their own lives. Most people who die by suicide are mentally ill but some people take their lives because stressful events (the loss of a partner, for example) have made life seem worthless or too painful to bear. Strategies to reduce suicide rates include better treatment of mental illness and programs that help people at high risk of suicide deal with stress. Suicide rates can also be reduced by limiting access to common suicide methods. These methods differ from place to place. Hanging is the predominant suicide method in many countries but, in Hong Kong, for example, jumping from a high building is the commonest method. Suicide methods also vary over time. In 1998, a woman in Hong Kong took her life by burning barbecue charcoal in a sealed room (a process that produces high levels of the toxic gas carbon monoxide). This method was unheard of before and was extensively reported by the mass media; by the end of 2004, charcoal-burning suicide became the second most common form of suicide in Hong Kong.
Why Was This Study Done?
The epidemic of charcoal-burning suicide that started in Hong Kong has rapidly spread to other countries in East Asia, including Taiwan, where it is also now the second most common method of suicide. It would be useful to identify the factors that have contributed to the spread of this particular form of suicide because such knowledge might help to improve strategies for preventing charcoal-burning suicide. One way to identify these factors is to examine the space–time clustering of charcoal-burning suicides. Clustering of specific types of suicides in both time and space usually occurs in settings such as institutions where the individuals who die by suicide have been in social contact. By contrast, clustering of specific types of suicide in time more than place is often associated with media coverage of events such as celebrity suicides, which can lead to imitative suicides. In this study, therefore, the researchers investigate the evolution of the epidemic of charcoal-burning suicide over time and across areas in Taiwan.
What Did the Researchers Do and Find?
The researchers obtained data on suicides and undetermined deaths (most “missed” suicides are recorded as undetermined deaths) from 1999 to 2007 from the Taiwan Department of Health. They then used statistical methods to estimate the standardized mortality rates (the ratio of the observed to the expected numbers of deaths) of charcoal-burning and non-charcoal-burning suicides and undetermined deaths in different areas of Taiwan. The proportion of suicides that were charcoal-burning suicides rose from 0.1% in 1991 to 26.6% in 2007, they report, and the epidemic of charcoal-burning suicide was more marked in urban than in rural areas. However, there was no single point of origin of the epidemic. Finally, they report, rates of charcoal-burning suicide were consistently higher in urban than in rural areas throughout the study period, a result that means that, although overall suicide rates were higher in rural than in urban regions of Taiwan prior to the epidemic of charcoal-burning suicide, the difference has now almost disappeared.
What Do These Findings Mean?
These findings suggest that the epidemic of charcoal-burning suicide may underlie recent changes in the geography of suicide in Taiwan. However, the study's findings may not be numerically accurate because of some of the assumptions made by the researchers. For example, there is no specific code for charcoal-burning suicides in official records so the researchers assumed that suicides classified as “poisoning using nondomestic gas” were all charcoal-burning suicides, although other studies have shown that nearly 90% of deaths in the category were indeed charcoal-burning suicides. Nevertheless, the observed geographical pattern of charcoal-burning suicides and the changes in this pattern over time suggest that widespread media coverage and easy access to barbecue coal in supermarkets and convenience stores may have contributed to the epidemic of charcoal-burning suicide and to the increase in overall suicide rate in Taiwan and elsewhere in East Asia. Thus, guidelines that encourage responsible media reporting of charcoal-burning suicide (that is, reporting that does not contain detailed descriptions of the method or suggest that this type of suicide is easy and painless) and strategies that restrict access to barbecue charcoal may help to halt the epidemic of charcoal-burning suicide in East Asia.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000212.
Another PLoS Medicine research article by David Studdert and colleagues investigates the relationship between changes in vehicle emissions laws and the incidence of suicide by motor vehicle exhaust gas in Australia
The World Health Organization provides information on the global burden of suicide and on suicide prevention (in several languages); see also the article Methods of Suicide: International Suicide Patterns Derived from the WHO Mortality Database
The US National Institute of Mental Health provides information on suicide and suicide prevention
The UK National Health Service Choices website has detailed information about suicide and its prevention
MedlinePlus provides links to further resources about suicide (in English and Spanish)
The Taiwan Suicide Prevention Center provides information on suicide and its prevention in Taiwan (in Chinese)
The Centre for Suicide Research and Prevention, the University of Hong Kong, provides information on suicide and its prevention in Hong Kong (in Chinese and English)
doi:10.1371/journal.pmed.1000212
PMCID: PMC2794367  PMID: 20052273
23.  The Use of Facebook Advertising for Communicating Public Health Messages: A Campaign Against Drinking During Pregnancy in New Zealand 
Background
Social media is gaining recognition as a platform for delivering public health messages. One area attracting attention from public health researchers and professionals is Facebook’s advertising channel. This channel is reported to have a broad reach and generate high user engagement with the disseminated campaign materials. However, to date, no study has examined the communication process via this channel which this study aimed to address.
Objective
The specific objectives of the study were to (1) examine user engagement for a public health campaign based on the metadata provided by Facebook, (2) analyze comments generated by the campaign materials using text mining, and (3) investigate the relationship between the themes identified in the comments and the message and the sentiments prevalent in the themes that exhibited significant relationships.
Methods
This study examined a New Zealand public health pilot campaign called “Don’t Know? Don’t Drink,” which warned against drinking alcohol during pregnancy. The campaign conveyed the warning through a video and three banner ads that were delivered as news feeds to women aged 18-30 years. Thematic analysis using text mining performed on the comments (n=819) identified four themes. Logistic regression was used to identify meaning-making themes that exhibited association with the message.
Results
The users’ engagement was impressive with the video receiving 203,754 views. The combined likes and shares for the promotional materials (video and banner ads) amounted to 6125 and 300, respectively. The logistic regression analysis showed two meaning-making themes, namely, risk of pregnancy (P=.003) and alcohol and culture (P<.001) exhibited association with the message. The sentiment analysis carried out on the two themes revealed there were more negative than positive comments (47% vs 28%).
Conclusions
The user engagement observed in this study was consistent with previous research. The numbers reported for views, likes, and shares may be seen as unique interactions over the fixed period of the campaign; however, survey research would be required to find out the true evaluative worth of these metadata. A close examination of the comments, employing text mining, revealed that the message was not accepted by a majority of the target segment. Self-identity and conformity theories may help to explain these observed reactions, albeit warrant further investigations. Although the comments were predominantly negative, they provide opportunities to engage back with the women. The one-way communication format followed in this campaign did not support any two-way engagement. Further investigation is warranted to establish whether using a two-way communication format would have improved the acceptability of such public health messages delivered via social media. The findings of this study caution using a one-way communication format to convey public health messages via Facebook’s advertising channel.
doi:10.2196/publichealth.7032
PMCID: PMC5571231  PMID: 28798011
social media; health promotion; alcohol; pregnancy; New Zealand
24.  Assessment of a Media Campaign and Related Crisis Help Line Following Hurricane Katrina 
Public Health Reports  2008;123(5):646-651.
SYNOPSIS
Objectives.
We evaluated the impact of a media campaign targeting stress and depression following Hurricane Katrina. We specifically examined public response to the campaign's recommendation that people could contact a telephone help line for further assistance if needed.
Methods.
Call data from Via Link allowed us to track trends in 800-number Crisis Line call volume (n=29,659), which is the number recommended in the media campaign, and 2-1-1 Information and Referral Line call volume (n=8,035), which is employed in a control-like manner. With data from April 1, 2006, through November 30, 2006, multivariate analysis was used to assess trends and differences among and within pre-intervention, intervention, and post-intervention.
Results.
Information and Referral Line call volume, which was unrelated to the campaign, did not change over time. In contrast, Crisis Line call volume, which was related to the campaign, increased significantly from pre-intervention to intervention, but not from intervention to post-intervention. Furthermore, the daily rate of Crisis Line call volume was constant during pre-intervention, increased during intervention, but decreased during post-intervention.
Conclusion.
There is support for the media campaign's influence on public behavior to contact Via Link in regard to stress and depression following Hurricane Katrina. Analysis helps undermine alternative explanations, including general trends in help line call volume and those specific to Crisis Line call volume.
PMCID: PMC2496938  PMID: 18828420
25.  Evaluating User Experiences of the Secure Messaging Tool on the Veterans Affairs’ Patient Portal System 
Background
The United States Department of Veterans Affairs has implemented an electronic asynchronous “Secure Messaging” tool within a Web-based patient portal (ie, My HealtheVet) to support patient-provider communication. This electronic resource promotes continuous and coordinated patient-centered care, but to date little research has evaluated patients’ experiences and preferences for using Secure Messaging.
Objective
The objectives of this mixed-methods study were to (1) characterize veterans’ experiences using Secure Messaging in the My HealtheVet portal over a 3-month period, including system usability, (2) identify barriers to and facilitators of use, and (3) describe strategies to support veterans’ use of Secure Messaging.
Methods
We recruited 33 veterans who had access to and had previously used the portal’s Secure Messaging tool. We used a combination of in-depth interviews, face-to-face user-testing, review of transmitted secure messages between veterans and staff, and telephone interviews three months following initial contact. We assessed participants’ computer and health literacy during initial and follow-up interviews. We used a content-analysis approach to identify dominant themes in the qualitative data. We compared inferences from each of the data sources (interviews, user-testing, and message review) to identify convergent and divergent data trends.
Results
The majority of veterans (27/33, 82%) reported being satisfied with Secure Messaging at initial interview; satisfaction ratings increased to 97% (31/32, 1 missing) during follow-up interviews. Veterans noted Secure Messaging to be useful for communicating with their primary care team to manage health care needs (eg, health-related questions, test requests and results, medication refills and questions, managing appointments). Four domains emerged from interviews: (1) perceived benefits of using Secure Messaging, (2) barriers to using Secure Messaging, (3) facilitators for using Secure Messaging, and (4) suggestions for improving Secure Messaging. Veterans identified and demonstrated impediments to successful system usage that can be addressed with education, skill building, and system modifications. Analysis of secure message content data provided insights to reasons for use that were not disclosed by participants during interviews, specifically sensitive health topics such as erectile dysfunction and sexually transmitted disease inquiries.
Conclusions
Veterans perceive Secure Messaging in the My HealtheVet patient portal as a useful tool for communicating with health care teams. However, to maximize sustained utilization of Secure Messaging, marketing, education, skill building, and system modifications are needed. Data from this study can inform a large-scale quantitative assessment of Secure Messaging users’ experiences in a representative sample to validate qualitative findings.
doi:10.2196/jmir.2976
PMCID: PMC3961805  PMID: 24610454
veterans; secure messaging; patient-provider communication; Department of Veterans Affairs; usability testing; mixed methods; patient-centered care

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