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1.  No Child or Mother Left Behind; Implications for the US from Cuba’s Maternity Homes 
Background: Cuba, a “resource-poor” country, provides high-quality, free maternal care despite relatively low per capita health expenditures in comparison to similar expenditures in “resource rich” nations such as Canada and the US. This paper assesses maternal and child healthcare in Cuba, details the system of community-based regional maternity homes, and outlines specific recommendations for the US.
Methods: Based on observations during a visit to Cuba, and supplemental research on international health expenditures and health indicators such as infant and maternal mortality, this paper details maternal and child health in Cuba.
Results: Cuba utilizes community-based regional maternity homes to provide comprehensive care for women with high-risk pregnancies. This effective strategy of investing in maternal health by safeguarding pregnancies has lowered infant and maternal mortality rates significantly. Cuba has achieved neonatal, infant and under-five mortality rates that are better than or on par with resource rich nations such as the US. Additionally, within the Latin American and Caribbean region, Cuba has a low rate of maternal mortality.
Conclusion: Positioning maternal and child health priorities to the policy foreground were a critical step in saving the lives of Cuban women and children. The US may benefit from Cuba's example with respect to maternal and child health. Cuba's model provides important health; rights and policy lessons for all nations—are they resource rich or poor.
PMCID: PMC3963654  PMID: 24688913
Maternal and child health; Community health; Public health; Cuba
2.  Clinical Research After Catastrophic Disasters: Lessons Learned From Hurricane Katrina 
When catastrophic disasters such as Hurricane Katrina strike, psychologists and other mental health professionals often wonder how to use resources and fill needed roles. We argue that conducting clinical research in response to disasters is 1 important way that these professionals can contribute. However, we recognize that designing and implementing a clinical research study can be a daunting task, particularly in the context of the personal and system-wide chaos that follows most disasters. Thus, we offer a detailed description of our own experiences with conducting clinical research as part of our response to Hurricane Katrina. We describe our study design, recruitment and data collection efforts, and summarize and synthesize the lessons we have learned from this endeavor. Our hope is that others who may wish to conduct disaster-related research will learn from our mistakes and successes.
PMCID: PMC2631178  PMID: 19177173
clinical research; disasters; Hurricane Katrina; roles
3.  Five Years Later: Recovery from Post Traumatic Stress and Psychological Distress Among Low-Income Mothers Affected by Hurricane Katrina 
Social science & medicine (1982)  2011;74(2):150-157.
Hurricane Katrina, which struck the Gulf Coast of the United States in August 2005, exposed area residents to trauma and extensive property loss. However, little is known about the long-run effects of the hurricane on the mental health of those who were exposed. This study documents long-run changes in mental health among a particularly vulnerable group—low income mothers—from before to after the hurricane, and identifies factors that are associated with different recovery trajectories. Longitudinal surveys of 532 low-income mothers from New Orleans were conducted approximately one year before, 7 to 19 months after, and 43 to 54 months after Hurricane Katrina. The surveys collected information on mental health, social support, earnings and hurricane experiences. We document changes in post-traumatic stress symptoms (PTSS), as measured by the Impact of Event Scale-Revised, and symptoms of psychological distress (PD), as measured by the K6 scale. We find that although PTSS has declined over time after the hurricane, it remained high 43 to 54 months later. PD also declined, but did not return to pre-hurricane levels. At both time periods, psychological distress before the hurricane, hurricane-related home damage, and exposure to traumatic events were associated with PTSS that co-occurred with PD. Hurricane-related home damage and traumatic events were associated with PTSS without PD. Home damage was an especially important predictor of chronic PTSS, with and without PD. Most hurricane stressors did not have strong associations with PD alone over the short or long run. Over the long run, higher earnings were protective against PD, and greater social support was protective against PTSS. These results indicate that mental health problems, particularly PTSS alone or in co-occurrence with PD, among Hurricane Katrina survivors remain a concern, especially for those who experienced hurricane-related trauma and had poor mental health or low socioeconomic status before the hurricane.
PMCID: PMC3286602  PMID: 22137245
Mental health; natural disasters; Hurricane Katrina; USA; women
4.  The Nontraditional Role of Pharmacists After Hurricane Katrina: Process Description and Lessons Learned 
Public Health Reports  2009;124(2):217-223.
In the week before Hurricane Katrina's landfall in August 2005, emergency management officials in Jefferson County (Birmingham), Alabama, began to make plans for the potential influx of evacuees from the Gulf Coast. No pharmacy component to the plan was in place at that time. The Jefferson County Department of Health (JCDH) discovered that local pharmacies and hospital emergency departments were dealing with significant requests for medication refills. JCDH, in cooperation with a local school of pharmacy, developed a plan for addressing the unforeseen need for routine prescription refills by evacuees. This article discusses this novel pharmacy plan and lessons learned from the event, and may serve as a model for other municipalities and/or states interested in preparing a pharmacy response to future natural disasters.
PMCID: PMC2646478  PMID: 19320363
5.  Lessons from Hurricane Sandy: a Community Response in Brooklyn, New York 
The frequency and intensity of extreme weather events have increased in recent decades; one example is Hurricane Sandy. If the frequency and severity continue or increase, adaptation and mitigation efforts are needed to protect vulnerable populations and improve daily life under changed weather conditions. This field report examines the devastation due to Hurricane Sandy experienced in Red Hook, Brooklyn, New York, a neighborhood consisting of geographically isolated low-lying commercial and residential units, with a concentration of low-income housing, and disproportionate rates of poverty and poor health outcomes largely experienced by Black and Latino residents. Multiple sources of data were reviewed, including street canvasses, governmental reports, community flyers, and meeting transcripts, as well as firsthand observations by a local nonprofit Red Hook Initiative (RHI) and community members, and social media accounts of the effects of Sandy and the response to daily needs. These data are considered within existing theory, evidence, and practice on protecting public health during extreme weather events. Firsthand observations show that a community-based organization in Red Hook, RHI, was at the center of the response to disaster relief, despite the lack of staff training in response to events such as Hurricane Sandy. Review of these data underscores that adaptation and response to climate change and likely resultant extreme weather is a dynamic process requiring an official coordinated governmental response along with on-the-ground volunteer community responders.
PMCID: PMC3795193  PMID: 24022182
Climate change; Vulnerable populations; Community engagement
6.  Public health and Hurricane Katrina: lessons learned and what we can do now. 
Keith C. Ferdinand, MD, FACC, presently resides in Atlanta, GA, displaced from his native New Orleans by Hurricane Katrina, September 2005. The hurricane destroyed hiss cardiovascular center and severely damaged his home. In Atlanta, he is director of the Association of Black Cardiologists Hurricane Katrina Relief.
PMCID: PMC2595083  PMID: 16708514
7.  Health Care: Lessons from China and Cuba 
Health has improved in Cuba and China during the past quarter of a century. Some of the improvements in health occurred as economic conditions improved in both countries, but there are other similarities of health care delivery in China and Cuba. Collective activity plays an important role in health care in both nations; both do health planning centrally, but local communities control the daily activities of the health services that they use. Techniques that have improved health in underdeveloped nations might be applied in underserved areas of the United States.
PMCID: PMC2552869  PMID: 7120476
8.  Services Oriented Architectures and Rapid Deployment of Ad-Hoc Health Surveillance Systems: Lessons from Katrina Relief Efforts 
During the Hurricane Katrina relief efforts, a new city was born overnight within the City of Houston to provide accommodation and health services for thousands of evacuees deprived of food, rest, medical attention, and sanitation [1]. The hurricane victims had been exposed to flood water, toxic materials, physical injury, and mental stress. This scenario was an invitation for a variety of public health hazards, primarily infectious disease outbreaks. Early detection and monitoring of morbidity and mortality among evacuees due to unattended health conditions was an urgent priority and called for deployment of real-time surveillance to collect and analyze data at the scene, and to enable and guide appropriate response and planning activities [2].
To address this need, the University of Texas Health Science Center at Houston (UTHSC) and the Houston Department of Health and Human Services (HDHHS) deployed an ad hoc surveillance system overnight by leveraging Internet-based technologies and Services Oriented Architecture (SOA) [3, 4].
The system was post-coordinated through the orchestration of Web Services such as information integration, natural language processing, UMLS terminology services, syndromic case finding, and online analytical processing (OLAP) [5]. Here we will report the use of Internet-based and distributed architectures in providing timely, novel, and customizable solutions just in time for unprecedented events such as natural disasters.
PMCID: PMC1839532  PMID: 17238405
9.  Trends in Serious Emotional Disturbance among Youths Exposed to Hurricane Katrina 
To examine patterns and predictors of trends in DSM-IV serious emotional disturbance (SED) among youths exposed to Hurricane Katrina.
A probability sample of adult pre-hurricane residents of the areas affected by Katrina completed baseline and follow-up telephone surveys 18-27 months post-hurricane and 12-18 months later. Baseline adult respondents residing with children (ages 4-17) provided informant reports about the emotional functioning of these youths (n = 576) with the Strengths and Difficulties Questionnaire (SDQ). The surveys also assessed hurricane-related stressors and ongoing stressors experienced by respondent families.
SED prevalence decreased significantly across survey waves from 15.1% to 11.5%, although even the latter prevalence was considerably higher than the pre-hurricane prevalence of 4.2% estimated in the US National Health Interview Survey. Trends in hurricane-related SED were predicted by both stressors experienced in the hurricane and ongoing stressors, with SED prevalence decreasing significantly only among youths with moderate stress exposure (16.8% vs. 6.5%). SED prevalence did not change significantly between waves among youths with either high stress exposure (30.0% vs. 41.9%) or low stress exposure (3.5% vs. 3.4%). Pre-hurricane functioning did not predict SED persistence among youths with high stress exposure, but did predict SED persistence among youth with low-moderate stress exposure.
The prevalence of SED among youths exposed to Hurricane Katrina remains significantly elevated several years after the storm despite meaningful decrease since baseline. Youths with high stress exposure have the highest risk of long-term hurricane-related SED and consequently represent an important target for mental health intervention.
PMCID: PMC3228600  PMID: 20855044
Hurricane Katrina; SED; natural disaster; child mental health; stress
Contemporary clinical trials  2008;29(5):756-761.
Hurricane Katrina was one of the most catastrophic natural disasters to hit the United States. It had a major impact on health care in New Orleans, LA and the surrounding region, not only in relation to acute illness but also chronic disease. When Hurricane Katrina struck New Orleans on August 29, 2005, there were 193 participants being followed in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial at Tulane University Health Sciences Center. In the immediate aftermath of the storm, the Tulane University ACCORD Study site, in collaboration with the Study Coordinating Center and the Southeast Clinical Center Network office of the trial at Wake Forest University Health Sciences in North Carolina, took several actions in order to locate the participants, ensure their safety, and maintain the scientific integrity of the trial. We describe the actions taken and the relative success/failure of such actions.
PMCID: PMC2607140  PMID: 18577469
11.  Predicting Mothers’ Reports of Children’s Mental Health Three Years after Hurricane Katrin 
This study explored pathways through which hurricane-related stressors affected the psychological functioning of elementary school aged children who survived Hurricane Katrina. Participants included 184 mothers from the New Orleans area who completed assessments one year pre-disaster (Time 1), and one and three years post-disaster (Time 2 and Time 3, respectively). Mothers rated their children’s behavior problems at Time 3 only (n = 251 children; 53.0% male; Mean age: 10.19 years, SD = 1.68 years). A path analytic model indicated that hurricane-related stressors were associated with increased maternal psychological distress and school mobility in the first post-disaster year, which were associated with higher child internalizing and externalizing symptoms three years post-disaster. Mediation analysis indicated that hurricane-related stressors were associated with child symptoms indirectly, through their impact on maternal psychological distress. Findings underscore the importance of interventions that boost maternal and child mental health and support children through post-disaster school transitions.
PMCID: PMC3587107  PMID: 23471125
natural disasters; elementary school students; low-income families; maternal psychological distress; child behavior problems
12.  Child health nurses in the Solomon Islands: lessons for the Pacific and other developing countries 
To understand the roles of nurses with advanced training in paediatrics in the Solomon Islands, and the importance of these roles to child health. To understand how adequately equipped child health nurses feel for these roles, to identify the training needs, difficulties and future opportunities.
Semi-structured interviews.
Tertiary hospital, district hospitals and health clinics in the Solomon Islands.
Twenty-one paediatric nurses were interviewed out of a total of 27 in the country.
All nurses were currently employed in teaching, clinical or management areas. At least one or two nurses were working in each of 7 of the 9 provinces; in the two smaller provinces there were none. Many nurses were sole practitioners in remote locations without back-up from doctors or other experienced nurses; all had additional administrative or public health duties. Different types of courses were identified: a residential diploma through the University of Papua New Guinea or New Zealand and a diploma by correspondence through the University of Sydney.
Child health nurses in the Solomon Islands fulfill vital clinical, public health, teaching and administrative roles. Currently they are too few in number, and this is a limiting factor for improving the quality of child health services in that country. Current methods of training require overseas travel, or are expensive, or lack relevance, or remove nurses from their work-places and families for prolonged periods of time. A local post-basic child health nursing course is urgently needed, and models exist to achieve this.
PMCID: PMC3545833  PMID: 23171144
Solomon Islands; Child health; Nurses; Developing countries; Pacific Islands
13.  Exposure to Hurricane Katrina, Post-Traumatic Stress Disorder and Birth Outcomes 
Little is known about the effects of natural disasters on pregnancy outcomes. We studied mental health and birth outcomes among women exposed to Hurricane Katrina.
We collected data prospectively from a cohort of 301 women from New Orleans and Baton Rouge. Pregnant women were interviewed during pregnancy about their experiences during the hurricane, as well as whether they had experienced symptoms of post-traumatic stress disorder (PTSD) and/or depression. High hurricane exposure was defined as having three or more of the eight severe hurricane experiences, such as feeling that one's life was in danger, walking through floodwaters, or having a loved one die.
The frequency of low birth weight was higher in women with high hurricane exposure (14.0%) than women without high hurricane exposure (4.7%), with an adjusted odds ratio (aOR): 3.3; 95% confidence interval (CI): 1.13−9.89; p<0.01. The frequency of preterm birth was higher in women with high hurricane exposure (14.0%) than women without high hurricane exposure (6.3%), with aOR: 2.3; 95% CI: 0.82−6.38; p>0.05. There were no significant differences in the frequency of low birth weight or preterm birth between women with PTSD or depression and women without PTSD or depression (p>0.05).
Women who had high hurricane exposure were at an increased risk of having low birth weight infants. Rather than a general exposure to disaster, exposure to specific severe disaster events and the intensity of the disaster experience may be better predictors of poor pregnancy outcomes. To prevent poor pregnancy outcomes during and after disasters, future disaster preparedness may need to include the planning of earlier evacuation of pregnant women to minimize their exposure to severe disaster events.
PMCID: PMC2635112  PMID: 18703903
Depression; disaster; low birth weight; post-traumatic stress disorder; pregnancy
14.  Analysis of policy implications and challenges of the Cuban health assistance program related to human resources for health in the Pacific 
Cuba has extended its medical cooperation to Pacific Island Countries (PICs) by supplying doctors to boost service delivery and offering scholarships for Pacific Islanders to study medicine in Cuba. Given the small populations of PICs, the Cuban engagement could prove particularly significant for health systems development in the region. This paper reviews the magnitude and form of Cuban medical cooperation in the Pacific and analyses its implications for health policy, human resource capacity and overall development assistance for health in the region.
We reviewed both published and grey literature on health workforce in the Pacific including health workforce plans and human resource policy documents. Further information was gathered through discussions with key stakeholders involved in health workforce development in the region.
Cuba formalised its relationship with PICs in September 2008 following the first Cuba-Pacific Islands ministerial meeting. Some 33 Cuban health personnel work in Pacific Island Countries and 177 Pacific island students are studying medicine in Cuba in 2010 with the most extensive engagement in Kiribati, the Solomon Islands, Tuvalu and Vanuatu. The cost of the Cuban medical cooperation to PICs comes in the form of countries providing benefits and paying allowances to in-country Cuban health workers and return airfares for their students in Cuba. This has been seen by some PICs as a cheaper alternative to training doctors in other countries.
The Cuban engagement with PICs, while smaller than engagement with other countries, presents several opportunities and challenges for health system strengthening in the region. In particular, it allows PICs to increase their health workforce numbers at relatively low cost and extends delivery of health services to remote areas. A key challenge is that with the potential increase in the number of medical doctors, once the local students return from Cuba, some PICs may face substantial rises in salary expenditure which could significantly strain already stretched government budgets. Finally, the Cuban engagement in the Pacific has implications for the wider geo-political and health sector support environment as the relatively few major bilateral donors, notably Australia (through AusAID) and New Zealand (through NZAID), and multilaterals such as the World Bank will need to accommodate an additional player with whom existing links are limited.
PMCID: PMC3447691  PMID: 22558940
15.  Understanding the mental health of youth living with perinatal HIV infection: lessons learned and current challenges 
Across the globe, children born with perinatal HIV infection (PHIV) are reaching adolescence and young adulthood in large numbers. The majority of research has focused on biomedical outcomes yet there is increasing awareness that long-term survivors with PHIV are at high risk for mental health problems, given genetic, biomedical, familial and environmental risk. This article presents a review of the literature on the mental health functioning of perinatally HIV-infected (PHIV+) adolescents, corresponding risk and protective factors, treatment modalities and critical needs for future interventions and research.
An extensive review of online databases was conducted. Articles including: (1) PHIV+ youth; (2) age 10 and older; (3) mental health outcomes; and (4) mental health treatment were reviewed. Of 93 articles identified, 38 met inclusion criteria, the vast majority from the United States and Europe.
These studies suggest that PHIV+ youth experience emotional and behavioural problems, including psychiatric disorders, at higher than expected rates, often exceeding those of the general population and other high-risk groups. Yet, the specific role of HIV per se remains unclear, as uninfected youth with HIV exposure or those living in HIV-affected households displayed similar prevalence rates in some studies, higher rates in others and lower rates in still others. Although studies are limited with mixed findings, this review indicates that child-health status, cognitive function, parental health and mental health, stressful life events and neighbourhood disorder have been associated with worse mental health outcomes, while parent–child involvement and communication, and peer, parent and teacher social support have been associated with better function. Few evidence-based interventions exist; CHAMP+, a mental health programme for PHIV+ youth, shows promise across cultures.
This review highlights research limitations that preclude both conclusions and full understanding of aetiology. Conversely, these limitations present opportunities for future research. Many PHIV+ youth experience adequate mental health despite vulnerabilities. However, the focus of research to date highlights the identification of risks rather than positive attributes, which could inform preventive interventions. Development and evaluation of mental health interventions and preventions are urgently needed to optimize mental health, particularly for PHIV+ youth growing up in low-and-middle income countries.
PMCID: PMC3687078  PMID: 23782478
mental health; psychiatric disorders; emotional and behavioural problems; perinatal HIV infection; adolescence; paediatric HIV
16.  Increased sex ratio in Russia and Cuba after Chernobyl: a radiological hypothesis 
Environmental Health  2013;12:63.
The ratio of male to female offspring at birth may be a simple and non-invasive way to monitor the reproductive health of a population. Except in societies where selective abortion skews the sex ratio, approximately 105 boys are born for every 100 girls. Generally, the human sex ratio at birth is remarkably constant in large populations. After the Chernobyl nuclear power plant accident in April 1986, a long lasting significant elevation in the sex ratio has been found in Russia, i.e. more boys or fewer girls compared to expectation were born. Recently, also for Cuba an escalated sex ratio from 1987 onward has been documented and discussed in the scientific literature.
Presentation of the hypothesis
By the end of the eighties of the last century in Cuba as much as about 60% of the food imports were provided by the former Soviet Union. Due to its difficult economic situation, Cuba had neither the necessary insight nor the political strength to circumvent the detrimental genetic effects of imported radioactively contaminated foodstuffs after Chernobyl. We propose that the long term stable sex ratio increase in Cuba is essentially due to ionizing radiation.
Testing of the hypothesis
A synoptic trend analysis of Russian and Cuban annual sex ratios discloses upward jumps in 1987. The estimated jump height from 1986 to 1987 in Russia measures 0.51% with a 95% confidence interval (0.28, 0.75), p value < 0.0001. In Cuba the estimated jump height measures 2.99% (2.39, 3.60), p value < 0.0001. The hypothesis may be tested by reconstruction of imports from the world markets to Cuba and by radiological analyses of remains in Cuba for Cs-137 and Sr-90.
Implications of the hypothesis
If the evidence for the hypothesis is strengthened, there is potential to learn about genetic radiation risks and to prevent similar effects in present and future exposure situations.
PMCID: PMC3765590  PMID: 23947741
Food contamination; Food export import; Human secondary sex ratio; Radiation induced genetic effects; Radioactive fallout
17.  Predicting Posttraumatic Stress Symptoms in Children Following Hurricane Katrina: A Prospective Analysis of the Effect of Parental Distress and Parenting Practices* 
Journal of traumatic stress  2010;23(5):582-590.
Research exhibits a robust relation between child hurricane exposure, parent distress, and child posttraumatic stress disorder (PTSD). This study explored parenting practices that could further explicate this association. Participants were 381 mothers and their children exposed to Hurricane Katrina. It was hypothesized that 3–7 months (T1) and 14–17 months (T2) post-Katrina: (a) hurricane exposure would predict child PTSD symptoms after controlling for history of violence exposure and (b) hurricane exposure would predict parent distress and negative parenting practices, which, in turn, would predict increased child PTSD symptoms. Hypotheses were partially supported. Hurricane exposure directly predicted child PTSD at T1 and indirectly at T2. Additionally, several significant paths emerged from hurricane exposure to parent distress and parenting practices, which were predictive of child PTSD.
PMCID: PMC4231140  PMID: 20925099
18.  Lessons Learned From Early Implementation of Option B+: The Elizabeth Glaser Pediatric AIDS Foundation Experience in 11 African Countries 
“Option B+” is a World Health Organization-recommended approach to prevent mother-to-child HIV transmission whereby all HIV-positive pregnant and lactating women initiate lifelong antiretroviral therapy (ART). This review of early Option B+ implementation experience is intended to inform Ministries of Health and others involved in implementing Option B+.
This implementation science study analyzed data from 11 African countries supported by the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) to describe early experience implementing Option B+. Data are from 4 sources: (1) national guidelines for prevention of mother-to-child HIV transmission and Option B+ implementation plans, (2) aggregated service delivery data between January 2013 and March 2014 from EGPAF-supported sites, (3) field visits to Option B+ implementation sites, and (4) relevant EGPAF research, quality improvement, and evaluation studies.
Rapid adoption of Option B+ led to large increases in percentage of HIV-positive pregnant women accessing ART in antenatal care. By the end of 2013, most programs reached at least 50% of HIV-positive women in antenatal care with ART, even in countries using a phased approach to implementation. Scaling up Option B+ through integrating ART in maternal and child health settings has required expansion of the workforce, and task shifting to allow nurse-led ART initiation has created staffing pressure on lower-level cadres for counseling and community follow-up. Complex data collection needs may be impairing data quality.
Early experiences with Option B+ implementation demonstrate promise. Continued program evaluation is needed, as is specific attention to counseling and support around initiation of lifetime ART in the context of pregnancy and lactation.
PMCID: PMC4251909  PMID: 25436817
prevention of mother-to-child transmission of HIV; antiretroviral therapy; Option B+; implementation science
19.  Telling Children They Have HIV: Lessons Learned from Findings of a Qualitative Study in Sub-Saharan Africa 
AIDS Patient Care and STDs  2010;24(4):247-256.
HIV-infected children in developing countries are living longer lives as they gain access to antiretroviral treatment programs. As they grow older, their parents/guardians are faced with the difficult decision of if, when, and how to inform their child of his/her HIV status. Both negative and positive social, psychological, and behavioral impacts of disclosure to children have been reported, including improved adherence to medication regimens. Understanding the disclosure process from the perspective of HIV positive children, therefore, is critical to developing these interventions. Through children's experiences we can learn about what works well, what needs to be strengthened, and what is missing in current disclosure practices. We conducted in-depth interviews with eight caregiver–child dyads in Kinshasa, Democratic Republic of the Congo. The children were in a comprehensive HIV pediatric care and treatment program and had already been told their HIV diagnosis. For the analysis we placed particular emphasis on children's reports of communication with their caregivers and health care providers about their illness. Patterns emerged of limited communication between children and their caregivers as well as their providers, before, during, and after disclosure. From the perspective of children in this study, disclosure was largely a discrete event rather than a process. Sociocultural contexts surrounding HIV/AIDS, as well as health status, variations in parent–child communication and the relationships between health providers and children under their care, should inform psychosocial interventions delivered alongside treatment programs.
PMCID: PMC2864057  PMID: 20397899
20.  The Clinical Effort Against Secondhand Smoke Exposure (CEASE) Intervention: A Decade of Lessons Learned 
To describe lessons learned in developing the CEASE tobacco control intervention.
Descriptive report.
Tobacco use and tobacco smoke exposure harm families in a multitude of ways. The child health care setting is the ideal location to address parental smoking and tobacco smoke exposure in children. Few interventions have been developed specifically for families in the child health care setting. One such intervention, the CEASE program, was developed with assistance from tobacco control experts, pediatric researchers, policy makers, and child health care clinicians to address parental smoking.
An effective tobacco cessation intervention can be developed in a systematic way that may not require extensive resources and expertise.
PMCID: PMC3874254  PMID: 24379645
21.  Opportunities for prevention and intervention with young children: lessons from the Canadian incidence study of reported child abuse and neglect 
The most effective way to provide support to caregivers with infants in order to promote good health, social, emotional and developmental outcomes is the subject of numerous debates in the literature. In Canada, each province adopts a different approach which range from universal to targeted programs. Nonetheless, each year a group of vulnerable infants is identified to the child welfare system with concerns about their well-being and safety. This study examines maltreatment-related investigations in Canada involving children under the age of one year to identify which factors determine service provision at the conclusion of the investigation.
A secondary analysis of the Canadian Incidence Study of Reported Child Abuse and Neglect CIS-2008 (PHAC, 2010) dataset was conducted. Multivariate analyses were conducted to understand the profile of investigations involving infants (n=1,203) and which predictors were significant in the decision to transfer a case to ongoing services at the conclusion of the investigation. Logistic Regression and Classification and Regression Trees (CART) were conducted to examine the relationship between the outcome and predictors.
The results suggest that there are three main sources that refer infants to the Canadian child welfare system: hospital, police, and non-professionals. Infant maltreatment-related investigations involve young caregivers who struggle with poverty, single-parenthood, drug/solvent and alcohol abuse, mental health issues, lack of social supports, and intimate partner violence. Across the three referral sources, primary caregiver risk factors are the strongest predictor of the decision to transfer a case to ongoing services.
Multivariate analyses indicate that the presence of infant concerns does not predict ongoing service provision, except when the infant is identified with positive toxicology at birth. The opportunity for early intervention and the need to tailor interventions for specific caregiver risk factors is discussed.
PMCID: PMC3575393  PMID: 23406620
Child welfare; Child maltreatment; Infants; Young parents; Referral source; Decision-making; Ongoing services
22.  Lessons learned from scaling up a community-based health program in the Upper East Region of northern Ghana 
The original CHPS model deployed nurses to the community and engaged local leaders, reducing child mortality and fertility substantially. Key scaling-up lessons: (1) place nurses in home districts but not home villages, (2) adapt uniquely to each district, (3) mobilize local resources, (4) develop a shared project vision, and (5) conduct “exchanges” so that staff who are initiating operations can observe the model working in another setting, pilot the approach locally, and expand based on lessons learned.
The original CHPS model deployed nurses to the community and engaged local leaders, reducing child mortality and fertility substantially. Key scaling-up lessons: (1) place nurses in home districts but not home villages, (2) adapt uniquely to each district, (3) mobilize local resources, (4) develop a shared project vision, and (5) conduct “exchanges” so that staff who are initiating operations can observe the model working in another setting, pilot the approach locally, and expand based on lessons learned.
Ghana's Community-Based Health Planning and Service (CHPS) initiative is envisioned to be a national program to relocate primary health care services from subdistrict health centers to convenient community locations. The initiative was launched in 4 phases. First, it was piloted in 3 villages to develop appropriate strategies. Second, the approach was tested in a factorial trial, which showed that community-based care could reduce childhood mortality by half in only 3 years. Then, a replication experiment was launched to clarify appropriate activities for implementing the fourth and final phase—national scale up. This paper discusses CHPS progress in the Upper East Region (UER) of Ghana, where the pace of scale up has been much more rapid than in the other 9 regions of the country despite exceedingly challenging economic, ecological, and social circumstances. The UER employed 5 strategies that facilitated scale up: (1) nurse recruitment from their home districts to improve worker morale and cultural grounding, balanced with some social distance from the village community to ensure client confidentiality, particularly regarding family planning use; (2) prioritization of CHPS planning and continuous review in management meetings to make necessary modifications to the initiative's approach; (3) community engagement and advocacy to local politicians to mobilize resources for financing start-up costs; (4) a shared and consistent vision about CHPS among health administration leaders to ensure appropriate resources and commitment to the initiative; and (5) knowledge exchange visits between new and advanced CHPS implementers to facilitate learning and scale up within and between districts.
PMCID: PMC4168550  PMID: 25276522
23.  Booster seats for child passengers: lessons for increasing their use 
Injury Prevention  2001;7(3):210-213.
Objective—To explore parental knowledge, attitudes, beliefs, and barriers to use of booster seats in cars for 4–8 year old children.
Methods—Three focus groups conducted by a professional marketing firm.
Results—Many parents were confused about the appropriate weight and age of children who should be in booster seats; most parents incorrectly identified the age at which it was safe to use a lap-shoulder belt. Legislation was viewed as a positive factor in encouraging use. Cost of seats was frequently cited as a barrier to ownership, as were child resistance, peer pressure from older children, the need to accommodate other children in the vehicle, and the belief that a lap belt was adequate. Messages from health care providers, emergency medical services, or law enforcement personnel were believed to be most effective.
Conclusion—Campaigns to promote booster seat use should address issues of knowledge about appropriate age and size of the child, cost, inadequacy of lap belts, and resistance to use by the child.
PMCID: PMC1730742  PMID: 11565986
24.  Mobile Health Applications to Assist Patients with Diabetes: Lessons Learned and Design Implications 
Self-management is critical to achieving diabetes treatment goals. Mobile phones and Bluetooth® can supportself-management and lifestyle changes for chronic diseases such as diabetes. A mobile health (mHealth) research platform—the Few Touch Application (FTA)—is a tool designed to support the self-management of diabetes. The FTA consists of a mobile phone-based diabetes diary, which can be updated both manually from user input and automatically by wireless data transfer, and which provides personalized decision support for the achievement of personal health goals. Studies and applications (apps) based on FTAs have included: (1) automatic transfer of blood glucose (BG) data; (2) short message service (SMS)-based education for type 1diabetes (T1DM); (3) a diabetes diary for type 2 diabetes (T2DM); (4) integrating a patient diabetes diary with health care (HC) providers; (5) a diabetes diary for T1DM; (6) a food picture diary for T1DM; (7) physical activity monitoring for T2DM; (8) nutrition information for T2DM; (9) context sensitivity in mobile self-help tools; and (10) modeling of BG using mobile phones.
We have analyzed the performance of these 10 FTA-based apps to identify lessons for designing the most effective mHealth apps. From each of the 10 apps of FTA, respectively, we conclude: (1) automatic BG data transfer is easy to use and provides reassurance; (2) SMS-based education facilitates parent-child communication in T1DM; (3) the T2DM mobile phone diary encourages reflection; (4) the mobile phone diary enhances discussion between patients and HC professionals; (5) the T1DM mobile phone diary is useful and motivational; (6) the T1DM mobile phone picture diary is useful in identifying treatment obstacles; (7) the step counter with automatic data transfer promotes motivation and increases physical activity in T2DM; (8) food information on a phone for T2DM should not be at a detailed level; (9) context sensitivity has good prospects and is possible to implement on today’s phones; and (10) BG modeling on mobile phones is promising for motivated T1DM users.
We expect that the following elements will be important in future FTA designs: (A) automatic data transfer when possible; (B) motivational and visual user interfaces; (C) apps with considerable health benefits in relation to the effort required; (D) dynamic usage, e.g., both personal and together with HC personnel, long-/short-term perspective; and (E) inclusion of context sensitivity in apps. We conclude that mHealth apps will empower patients to take a more active role in managing their own health.
PMCID: PMC3570855  PMID: 23063047
blood glucose; diabetes; mobile health; self-management; type 1 diabetes; type 2 diabetes
25.  Dealing with Missing Outcomes: Lessons from a Randomized Trial of a Prenatal Intervention to Prevent Early Childhood Caries  
Severe early childhood caries (S-ECC) affects 17% of 2-3 year old children in South Australia impacting on their general health and well-being. S-ECC is largely preventable by providing mothers with anticipatory guidance. Randomised controlled trials (RCTs) are the most decisive way to test this, but that approach suffers from near inevitable loss to follow-up that occurs with preventative strategies and distant outcome assessment.
We re-examined the results of an RCT to prevent S-ECC using sensitivity analyses and multiple imputation to test different assumptions about violation of random allocation (1%) and major loss to follow-up (32%). Irrespective of any assumptions about missing outcomes, providing expectant mothers with anticipatory guidance during pregnancy and in the child’s first year of life, significantly reduced the incidence of S-ECC at 20 months of age. However, the relative risk of S-ECC varied from 0.18 (95% confidence interval (CI): 0.06 – 0.52) to 0.70 (95% CI: 0.56 – 0.88). Also the ‘number needed to treat’ (NNT) to prevent one case of S-ECC varied 2.5-fold: from 8 to 20 women given anticipatory guidance. Multiple imputation provided a best estimate of 0.25 (95% CI: 0.11 – 0.56) for the relative risk and of 14 (95% CI: 10 – 33) for the number needed to treat.
Avoiding loss to follow-up is crucial in any RCT, but is difficult with preventative health care strategies. Instead of abandoning randomisation in such circumstances, sensitivity analyses and multiple imputation can consolidate the findings of an RCT and add extra value to the conclusions derived from it.
PMCID: PMC2944987  PMID: 20871748
Health promotion; early childhood caries; randomized controlled trial; multiple imputation; intention-to-treat; number needed to treat; sensitivity analysis; pregnancy; Zelen design.

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