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1.  Using Primary Care Parenting Interventions to Improve Outcomes in Children with Developmental Disabilities: A Case Report 
Case Reports in Pediatrics  2012;2012:150261.
Parenting is central to the health and well-being of children. Children with developmental disabilities have been shown to be at increased risk of developing emotional and behavioral problems. Parent training programs are effective interventions for improving child behavior and family functioning. This paper describes the outcomes of a brief 4-session parenting intervention (Primary Care Stepping Stones Triple P) targeting compliance and cooperative play skills in an 8-year-old girl with Asperger's disorder and ADHD combined type. The intervention was associated with decreases in child behavior problems, increases in parenting confidence, and decreases in dysfunctional parenting styles. This paper demonstrates that low-intensity parenting interventions can lead to significant improvements in child behavior and family functioning. Such brief interventions are cost effective, can be widely disseminated, and have been designed to be delivered within primary health care settings. Pediatricians can play a key role in identifying parents in need of assistance and in helping them access evidence-based parenting interventions.
doi:10.1155/2012/150261
PMCID: PMC3424646  PMID: 22928141
2.  Patient and practitioner characteristics predict brief alcohol intervention in primary care. 
BACKGROUND: The effectiveness of an evidence-based health care intervention depends on it being delivered consistently to appropriate patients. Brief alcohol intervention is known to be effective at reducing excessive drinking and its concomitant health and social problems. However, a recent implementation trial reported partial delivery of brief alcohol intervention by general practitioners (GPs) which is likely to have reduced its impact. AIM: To investigate patient-practitioner characteristics influencing brief alcohol intervention in primary care. DESIGN OF STUDY: Cross-sectional analysis of 12,814 completed Alcohol Use Disorders Identification Test (AUDIT) screening questionnaires. SETTING: Eighty-four GPs who had implemented a brief alcohol intervention programme in a previous trial based in the Northeast of England. METHOD: GPs were requested to screen all adults (aged over 16 years) presenting to their surgery and follow a structured protocol to give a brief intervention (five minutes of advice plus an information booklet) to all 'risk' drinkers. Anonymized carbon copies of the screening questionnaire were collected from all practices after a three-month implementation period. RESULTS: Although AUDIT identified 4080 'risk' drinkers, only 2043 (50%) received brief intervention. Risk drinkers that were most likely to receive brief intervention were males (58%), unemployed (61%), and technically-trained patients (55%). Risk drinkers that were least likely to receive brief intervention were females (44%), students (38%), and university educated patients (46%). Logistic regression modelling showed that patients' risk status was the most influential predictor of brief intervention. Also, GPs' experience of relevant training and longer average practice consultations predicted brief intervention. However, personal characteristics relating to patients and GPs also predicted brief intervention in routine practice. CONCLUSION: Interpersonal factors relating to patients and practitioners contributed to the selective provision of brief alcohol intervention in primary care. Ways should be found to remedy this situation or the impact of this evidence-based intervention may be reduced when implemented in routine practice.
PMCID: PMC1314128  PMID: 11677706
3.  The Influence of Neurocognitive Impairment on HIV Treatment Outcomes among Drug-involved People Living with HIV/AIDS 
AIDS Care  2012;24(3):386-393.
Findings to date indicate that it is feasible to deliver a brief behavioral risk reduction/medication adherence group intervention to HIV-infected IDUs in a community-based setting. HIV infection and substance abuse can result in neurocognitive impairment and this is directly relevant to intervention development because a significant number of people living with HIV/AIDS have a positive history of substance abuse and being able to successfully participate in behavioral interventions often requires a relatively high level of cognitive performance. The aim of the current study was to evaluate if changes in information, motivation and behavior skills with respect to medication adherence, sex- and drug-risk behavior outcomes from baseline to post-intervention is predicted by cognitive impairment following the brief 4-session Holistic Health for HIV intervention for HIV-infected Drug Users (3H+). Significant associations were found between change in motivation and certain neurocognitive performance domains. Findings suggest that it may be helpful to specifically tailor such behavioral interventions to accommodate cognitive impairment.
doi:10.1080/09540121.2011.608794
PMCID: PMC3294373  PMID: 22250847
4.  Alcohol Screening and Brief Intervention for Adolescents: The How, What and Where of Reducing Alcohol Consumption and Related Harm Among Young People 
Aim: The aim of the study was to explore the evidence base on alcohol screening and brief intervention for adolescents to determine age appropriate screening tools, effective brief interventions and appropriate locations to undertake these activities. Methods: A review of existing reviews (2003–2013) and a systematic review of recent research not included in earlier reviews. Results: The CRAFFT and AUDIT tools are recommended for identification of ‘at risk’ adolescents. Motivational interventions delivered over one or more sessions and based in health care or educational settings are effective at reducing levels of consumption and alcohol-related harm. Conclusion: Further research to develop age appropriate screening tools needs to be undertaken. Screening and brief intervention activity should be undertaken in settings where young people are likely to present; further assessment at such venues as paediatric emergency departments, sexual health clinics and youth offending teams should be evaluated. The use of electronic (web/smart-phone based) screening and intervention shows promise and should also be the focus of future research.
doi:10.1093/alcalc/agt165
PMCID: PMC3932830  PMID: 24232178
5.  Integrating Screening, Brief Intervention, and Referral to Treatment (SBIRT) into Clinical Practice Settings: A Brief Review 
Journal of psychoactive drugs  2012;44(4):307-317.
Screening, brief intervention, and referral to treatment (SBIRT) is a public health approach to the delivery of early intervention and treatment services for individuals at risk of developing substance use disorders (SUDs) and those who have already developed these disorders. SBIRT can be flexibly applied; therefore, it can be delivered in many clinical care settings. SBIRT has been adapted for use in hospital emergency settings, primary care centers, office- and clinic-based practices, and other community settings, providing opportunities for early intervention with at-risk substance users before more severe consequences occur. In addition, SBIRT interventions can include the provision of brief treatment for those with less severe SUDs and referrals to specialized substance abuse treatment programs for those with more severe SUDs. Screening large numbers of individuals presents an opportunity to engage those who are in need of treatment. However, additional research is needed to determine how best to implement SBIRT.
PMCID: PMC3801194  PMID: 23210379
brief intervention; referral to treatment; SBIRT; screening; substance use disorders
6.  Sleep well—be well study: improving school transition by improving child sleep: a translational randomised trial 
BMJ Open  2013;3(10):e004009.
Introduction
The transition to primary school appears crucial for a child's future academic and psychological well-being. Addressing conditions which negatively affect children during this period, such as poor sleep, may improve these outcomes. Sleep problems are common and in a previous efficacy randomised controlled trial, we demonstrated that sleep problems can be identified and improved using school-based screening followed by a brief behavioural intervention. This trial will determine whether the same intervention is beneficial and cost-effective when delivered by an existing school-based health workforce.
Methods/design
We will recruit 334 children with sleep problems from approximately 40 schools after screening for behavioural sleep problems in the first year of formal education (Grade Prep). Schools in Melbourne, Australia will be invited to participate from a randomly ordered list of eligible schools and we will approach all caregivers of Grade Prep children. Children who have a parent-reported moderate or severe sleep problem will be randomised into either ‘usual care’ or ‘intervention’ groups. Trained nurses from the Primary School Nursing programme will deliver the sleep intervention programme. Intervention: Two to three contacts between the nurse and the parent; initial 45 min face-to-face meeting or phone call, 15 min phone call 2 weeks later and an optional second 30 min face-to-face meeting. Follow-up: 6 and 12 months postrandomisation using parent and teacher surveys and child face-to-face assessments. Primary outcome: child psychosocial functioning at 6 months. Secondary outcomes: child psychosocial functioning at 12 months and child sleep, behaviour, working memory, academic achievement and parent mental health at 6 and 12 months. Cost-effectiveness analysis will compare incremental costs to difference in child psychosocial functioning at 6 months.
Registration
International Standard Randomised Controlled Trial Number Register (ISRCTN92448857).
doi:10.1136/bmjopen-2013-004009
PMCID: PMC3816243  PMID: 24165031
7.  Cost effectiveness of a computer-delivered intervention to improve HIV medication adherence 
Background
High levels of adherence to medications for HIV infection are essential for optimal clinical outcomes and to reduce viral transmission, but many patients do not achieve required levels. Clinician-delivered interventions can improve patients’ adherence, but usually require substantial effort by trained individuals and may not be widely available. Computer-delivered interventions can address this problem by reducing required staff time for delivery and by making the interventions widely available via the Internet. We previously developed a computer-delivered intervention designed to improve patients’ level of health literacy as a strategy to improve their HIV medication adherence. The intervention was shown to increase patients’ adherence, but it was not clear that the benefits resulting from the increase in adherence could justify the costs of developing and deploying the intervention. The purpose of this study was to evaluate the relation of development and deployment costs to the effectiveness of the intervention.
Methods
Costs of intervention development were drawn from accounting reports for the grant under which its development was supported, adjusted for costs primarily resulting from the project’s research purpose. Effectiveness of the intervention was drawn from results of the parent study. The relation of the intervention’s effects to changes in health status, expressed as utilities, was also evaluated in order to assess the net cost of the intervention in terms of quality adjusted life years (QALYs). Sensitivity analyses evaluated ranges of possible intervention effectiveness and durations of its effects, and costs were evaluated over several deployment scenarios.
Results
The intervention’s cost effectiveness depends largely on the number of persons using it and the duration of its effectiveness. Even with modest effects for a small number of patients the intervention was associated with net cost savings in some scenarios and for durations greater than three months and longer it was usually associated with a favorable cost per QALY. For intermediate and larger assumed effects and longer durations of intervention effectiveness, the intervention was associated with net cost savings.
Conclusions
Computer-delivered adherence interventions may be a cost-effective strategy to improve adherence in persons treated for HIV.
Trial registration
Clinicaltrials.gov identifier NCT01304186.
doi:10.1186/1472-6947-13-29
PMCID: PMC3599639  PMID: 23446180
HIV; Cost effectiveness analysis; QALY; Computer intervention; Medication adherence
8.  Randomised controlled trial of brief psychological intervention after deliberate self poisoning 
BMJ : British Medical Journal  2001;323(7305):135.
Objectives
To determine the effects of a brief psychological intervention (brief psychodynamic interpersonal therapy) for patients after deliberate self poisoning compared with usual treatment. To compare the impact of the active intervention and usual treatment on patients' satisfaction with care.
Design
Randomised controlled trial.
Participants
119 adults who had deliberately poisoned themselves and presented to the emergency department of a teaching hospital.
Setting
Community based study.
Intervention
Four sessions of therapy delivered in the patient's home. Control patients received “treatment as usual,” which in most cases consisted of referral back to their general practitioner.
Outcome measures
Severity of suicidal ideation six months after treatment as assessed by the Beck scale for suicidal ideation. Secondary outcome measures at six month follow up included depressive symptoms as measured by the Beck depression inventory, patient satisfaction with treatment, and self reported subsequent attempts at self harm.
Results
Participants randomised to the intervention had a significantly greater reduction in suicidal ideation at six month follow up compared with those in the control group (reduction in the mean (SD) Beck scale 8.0 v 1.5). They were more satisfied with their treatment and were less likely to report repeated attempts to harm themselves at follow up (proportion repeating 9% v 28% in control group; difference 19%, 95% confidence interval 9% to 30 %, P=0.009).
Conclusion
Brief psychodynamic interpersonal therapy may be a valuable treatment after people have deliberately tried to poison themselves.
What is already known on this topicDeliberate self poisoning is one of the commonest reasons for admission to hospital in the United Kingdom and up to 15% of patients who poison themselves eventually kill themselvesThere are no interventions of proved efficacy for these patientsMost episodes of self poisoning are precipitated by some form of interpersonal problemWhat this study addsCompared with usual treatment four sessions of psychodynamic interpersonal therapy reduced suicidal ideation and self reported attempts at self harmThe intervention also improved patients' satisfaction with care
PMCID: PMC34723  PMID: 11463679
9.  Multicentre aneurysm screening study (MASS): cost effectiveness analysis of screening for abdominal aortic aneurysms based on four year results from randomised controlled trial 
BMJ : British Medical Journal  2002;325(7373):1135.
Objective
To assess the cost effectiveness of ultrasound screening for abdominal aortic aneurysms.
Design
Primary analysis: four year cost effectiveness analysis based directly on results from a randomised controlled trial in which patients were individually allocated to invitation to ultrasound screening (intervention) or to a control group not offered screening. Secondary analysis: projection of the data, based on conservative assumptions, to indicate likely cost effectiveness at 10 years.
Setting
Four centres in the United Kingdom. Screening delivered in primary care settings with follow up and surgery offered in the main hospitals
Participants
Population based sample of 67 800 men aged 65-74 years.
Main outcome measures
Mortality from and costs (screening, follow up, elective and emergency surgery) related to abdominal aortic aneurysm; cost per life year gained.
Results
Over four years there were 47 fewer deaths related to abdominal aortic aneurysms in the screening group than in the control group, but the additional costs incurred were £2.2m. After adjustment for censoring and discounted at 6% the mean additional cost of the screening programme was £63.39 ($97.77, €100.48) (95% confidence interval £53.31 to £73.48) per patient. The hazard ratio for abdominal aortic aneurysm was 0.58 (0.42 to 0.78). Over four years the mean incremental cost effectiveness ratio for screening was £28 400 (£15 000 to £146 000) per life year gained, equivalent to about £36 000 per quality adjusted life year. After 10 years this figure is estimated to fall to around £8000 per life year gained.
Conclusions
Even at four years the cost effectiveness of screening for abdominal aortic aneurysms is at the margin of acceptability according to current NHS thresholds. Over a longer period the cost effectiveness will improve substantially, the predicted ratio at 10 years falling to around a quarter of the four year figure.
What is already known on this topicSmall trials have suggested that an ultrasound screening programme to detect abdominal aortic aneurysms in older men may be effectiveThere is uncertainty about the cost effectiveness of routine screening, with widely varying estimatesWhat this study addsA cost effectiveness analysis of data from a large randomised trial with follow up over four years showed 47 fewer deaths and additional costs of £2.2m in the group invited to screeningThe adjusted net cost per patient was £63.39 and per life year gained was £28 400The projected cost per life year gained after 10 years was £8000, which is substantially lower than the perceived NHS threshold value
PMCID: PMC133450  PMID: 12433761
10.  The Comparative Effectiveness of Individual and Group Brief Motivational Interventions for Mandated College Students 
Individual brief motivational intervention (iBMI) is an efficacious strategy to reduce heavy drinking by students who are mandated to receive an alcohol intervention following an alcohol-related event. However, despite the strong empirical support for iBMI, it is unknown if the results from rigorously controlled research on iBMI translate to real-world settings. Furthermore, many colleges lack the resources to provide iBMI to mandated students. Therefore, group-delivered BMI (gBMI) might be a cost-effective alternative that can be delivered to a large number of individuals. The purpose of this study was to conduct a comparative effectiveness evaluation of iBMI and gBMI as delivered by staff at a university health services center. Participants (N = 278) were college students who were mandated to receive an alcohol intervention following an alcohol-related incident. Participants were randomized to receive an individual (iBMI; n = 133) or a Group BMI (gBMI; n = 145). Results indicated that both iBMI and gBMI participants reduced their peak estimated blood alcohol concentration (BAC) and the number of negative alcohol-related consequences at 1-, 3-, and 6-months postintervention. The iBMI and gBMI conditions were not significantly different at follow-up. These findings provide preliminary support for the use of iBMI and gBMIs for college students in real-world settings.
doi:10.1037/a0034899
PMCID: PMC4062841  PMID: 24731111
brief intervention; personalized feedback; college drinking; mandated students; comparative effectiveness
11.  Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis 
BMJ : British Medical Journal  2003;327(7414):536-542.
Objective To determine the effectiveness of programmes of screening in general practice for excessive alcohol use and providing brief interventions.
Design Systematic review and meta-analysis of randomised controlled trials that used screening as a precursor to brief intervention.
Setting General practice.
Main outcome measures Number needed to treat, proportion of patients positive on screening, proportion given brief interventions, and effect of screening.
Results The eight studies included for meta-analysis all used health questionnaires for screening, and the brief interventions included feedback, information, and advice. The studies contained several sources of bias that might lead to overestimates of the effects of intervention. External validity was compromised because typically three out of four people identified by screening as excessive users of alcohol did not qualify for the intervention after a secondary assessment. Overall, in 1000 screened patients, 90 screened positive and required further assessment, after which 25 qualified for brief intervention; after one year 2.6 (95% confidence interval 1.7 to 3.4) reported they drank less than the maximum recommended level.
Conclusions Although even brief advice can reduce excessive drinking, screening in general practice does not seem to be an effective precursor to brief interventions targeting excessive alcohol use. This meta-analysis raises questions about the feasibility of screening in general practice for excessive use of alcohol.
PMCID: PMC192891  PMID: 12958114
12.  Health on the web: randomised trial of work-based online screening and brief intervention for hazardous and harmful drinking 
BMC Public Health  2013;13:505.
Background
Alcohol misuse is a significant international public health problem. Screening and brief intervention (SBI) in primary care reduces alcohol consumption by about 15 – 30%, sustained over 12 months in hazardous or harmful drinkers but implementation has proved difficult leading to growing interest in exploring the effectiveness of SBI in other settings, including the workplace. Computerised interventions for alcohol misuse can be as effective as traditional face-to-face interventions and may have advantages, including anonymity, convenience and availability.
Methods/design
Individually randomised controlled trial to determine the effectiveness and cost-effectiveness of offering online screening and brief intervention for alcohol misuse in a workplace. Participants: adults (aged 18 or over) employed by participating employers scoring 5 or more on a three item screen for alcohol misuse (the AUDIT-C) indicating possible hazardous or harmful alcohol consumption, recruited through the offer of an online health check providing screening for a range of health behaviours with personalised feedback. Participants who accept the health check and score 5 or more on the alcohol screen will be randomised to receiving immediate feedback on their alcohol consumption and access to an online intervention offering support in reducing alcohol consumption (Down Your Drink) or delayed feedback and access to Down Your Drink after completion of follow-up data at three months. All employees who take the online health check will receive personalised feedback on other screened health behaviours including diet, physical activity, smoking, and body mass index. The primary outcome is alcohol consumption in the past week at three months; secondary outcomes are the AUDIT, EQ-5D, days off work, number and duration of hospital admissions, costs and use of the intervention. A sample size of 1,472 participants (736 in each arm) provides 90% power with 5% significance to determine a 20% reduction in alcohol consumption. Outcomes between groups at three months will be compared following the intention to treat principle and economic analyses will follow NICE guidance.
Discussion
This innovative design avoids recruitment bias by not mentioning alcohol in the invitation and avoids reactivity of assessment by not collecting baseline data on alcohol consumption.
doi:10.1186/1471-2458-13-505
PMCID: PMC3671166  PMID: 23706155
Alcohol-related disorders; Alcohol; Screening and brief intervention; Internet; Randomised; Controlled trial; Workplace; Health promotion
13.  Implementing Evidence-Based Alcohol Interventions in a Resource-Limited Setting: Novel Delivery Strategies in Tomsk, Russia 
Harvard Review of Psychiatry  2012;20(1):58-67.
Effective implementation of evidence-based interventions in “real-world” settings can be challenging. Interventions based on externally valid trial findings can be even more difficult to apply in resource-limited settings, given marked differences—in provider experience, patient population, and health systems—between those settings and the typical clinical trial environment. Under the auspices of the Integrated Management of Physician-Delivered Alcohol Care for Tuberculosis Patients (IMPACT) study, a randomized, controlled effectiveness trial, and as an integrated component of tuberculosis treatment in Tomsk, Russia, we adapted two proven alcohol interventions to the delivery of care to 200 patients with alcohol use disorders. Tuberculosis providers performed screening for alcohol use disorders and also delivered naltrexone (with medical management) or a brief counseling intervention either independently or in combination as a seamless part of routine care. We report the innovations and challenges to intervention design, training, and delivery of both pharmacologic and behavioral alcohol interventions within programmatic tuberculosis treatment services. We also discuss the implications of these lessons learned within the context of meeting the challenge of providing evidence-based care in resource-limited settings.
doi:10.3109/10673229.2012.649121
PMCID: PMC3318976  PMID: 22335183
alcohol; global health; implementation; resource-limited settings; resource-poor settings; Russia; tuberculosis
14.  Implementing Evidence-Based Alcohol Interventions in a Resource-Limited Setting: Novel Delivery Strategies in Tomsk, Russia 
Harvard Review of Psychiatry  2012;20(1):58-67.
Effective implementation of evidence-based interventions in “real-world” settings can be challenging. Interventions based on externally valid trial findings can be even more difficult to apply in resource-limited settings, given marked differences—in provider experience, patient population, and health systems—between those settings and the typical clinical trial environment. Under the auspices of the Integrated Management of Physician-Delivered Alcohol Care for Tuberculosis Patients (IMPACT) study, a randomized, controlled effectiveness trial, and as an integrated component of tuberculosis treatment in Tomsk, Russia, we adapted two proven alcohol interventions to the delivery of care to 200 patients with alcohol use disorders. Tuberculosis providers performed screening for alcohol use disorders and also delivered naltrexone (with medical management) or a brief counseling intervention either independently or in combination as a seamless part of routine care. We report the innovations and challenges to intervention design, training, and delivery of both pharmacologic and behavioral alcohol interventions within programmatic tuberculosis treatment services. We also discuss the implications of these lessons learned within the context of meeting the challenge of providing evidence-based care in resource-limited settings. (Harv Rev Psychiatry 2012;20:58–67.)
doi:10.3109/10673229.2012.649121
PMCID: PMC3318976  PMID: 22335183
alcohol; global health; implementation; resource-limited settings; resource-poor settings; Russia; tuberculosis
15.  Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the randomised Multicentre Aneurysm Screening Study 
Objectives To assess whether the mortality benefit from screening men aged 65-74 for abdominal aortic aneurysm decreases over time, and to estimate the long term cost effectiveness of screening.
Design Randomised trial with 10 years of follow-up.
Setting Four centres in the UK. Screening and surveillance was delivered mainly in primary care settings, with follow-up and surgery offered in hospitals.
Participants Population based sample of 67 770 men aged 65-74.
Interventions Participants were individually allocated to invitation to ultrasound screening (invited group) or to a control group not offered screening. Patients with an abdominal aortic aneurysm detected at screening underwent surveillance and were offered surgery if they met predefined criteria.
Main outcome measures Mortality and costs related to abdominal aortic aneurysm, and cost per life year gained.
Results Over 10 years 155 deaths related to abdominal aortic aneurysm (absolute risk 0.46%) occurred in the invited group and 296 (0.87%) in the control group (relative risk reduction 48%, 95% confidence interval 37% to 57%). The degree of benefit seen in earlier years of follow-up was maintained in later years. Based on the 10 year trial data, the incremental cost per man invited to screening was £100 (95% confidence interval £82 to £118), leading to an incremental cost effectiveness ratio of £7600 (£5100 to £13 000) per life year gained. However, the incidence of ruptured abdominal aortic aneurysms in those originally screened as normal increased noticeably after eight years.
Conclusions The mortality benefit of screening men aged 65-74 for abdominal aortic aneurysm is maintained up to 10 years and cost effectiveness becomes more favourable over time. To maximise the benefit from a screening programme, emphasis should be placed on achieving a high initial rate of attendance and good adherence to clinical follow-up, preventing delays in undertaking surgery, and maintaining a low operative mortality after elective surgery. On the basis of current evidence, rescreening of those originally screened as normal is not justified.
Trial registration Current Controlled Trials ISRCTN37381646.
doi:10.1136/bmj.b2307
PMCID: PMC3272658  PMID: 19553269
16.  Costs and health effects of screening and delivery of hearing aids in Tamil Nadu, India: an observational study 
BMC Public Health  2009;9:135.
Background
The burden of disease of hearing disorders among adults is high, but a significant part goes undetected. Screening programs in combination with the delivery of hearing aids can alleviate this situation, but the economic attractiveness of such programs is unknown. This study aims to evaluate the population-level costs, effects and cost-effectiveness of alternative delivering hearing aids models in Tamil Nadu, India
Methods
In an observational study design, we estimated total costs and effects of two active screening programs in the community in combination with the provision of hearing aids at secondary care level, and the costs and effects of the provision of hearing aids at tertiary care level. Screening and hearing aid delivery costs were estimated on the basis of program records and an empirical assessment of health personnel time input. Household costs for seeking and undergoing hearing health care were collected with a questionnaire (see Additional file 2). Health effects were estimated on the basis of compliance with the hearing aid, and associated changes in disability, and were expressed in disability-adjusted life years (DALYs) averted.
Results
Active screening and provision of hearing aids at the secondary care level costs around Rs.7,000 (US$152) per patient, whereas provision of hearing aids at the tertiary care level costs Rs 5,693 (US$122) per patient. The cost per DALY averted was around RS 42,200 (US$900) at secondary care level and Rs 33,900 (US$720) at tertiary care level. The majority of people did consult other providers before being screened in the community. Costs of food and transport ranged between Rs. 2 (US$0,04) and Rs. 39 (US$0,83).
Conclusion
Active screening and provision of hearing aids at the secondary care level is slightly more costly than passive screening and fitting of hearing aids at the tertiary care level, but seems also able to reach a higher coverage of hearing aids services. Although crude estimates indicate that both passive and active screening programs can be cautiously considered as cost-effective according to international thresholds, important questions remain regarding the implementation of the latter.
doi:10.1186/1471-2458-9-135
PMCID: PMC2695455  PMID: 19435490
17.  Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and six months 
Drug and alcohol dependence  2008;99(1-3):280-295.
Objectives
Alcohol screening and brief interventions in medical settings can significantly reduce alcohol use. Corresponding data for illicit drug use is sparse. A Federally funded Screening, Brief Intervention, Referral to Treatment (SBIRT) service program, the largest of its kind to date, was initiated by the Substance Abuse and Mental Health Services Administration (SAMHSA) in a wide variety of medical settings. We compared illicit drug use at intake and six months after drug screening and interventions were administered.
Design
SBIRT services were implemented in a range of medical settings across six states. A diverse patient population (Alaska Natives, American Indians, African-Americans, Caucasians, Hispanics), was screened and offered score-based progressive levels of intervention (brief intervention, brief treatment, referral to specialty treatment). In this secondary analysis of the SBIRT service program, drug use data was compared at intake and at a six month follow-up, in a sample of a randomly selected population (10%) that screened positive at baseline.
Results
Of 459,599 patients screened, 22.7% screened positive for a spectrum of use (risky/problematic, abuse/addiction). The majority were recommended for a brief intervention (15.9%), with a smaller percentage recommended for brief treatment (3.2%) or referral to specialty treatment (3.7%). Among those reporting baseline illicit drug use, rates of drug use at 6 month follow-up (4 of 6 sites), were 67.7% lower (p < 0.001) and heavy alcohol use was 38.6% lower (p < 0.001), with comparable findings across sites, gender, race/ethnic, age subgroups. Among persons recommended for brief treatment or referral to specialty treatment, self-reported improvements in general health (p < 0.001), mental health (p < 0.001), employment (p < 0.001), housing status (p < 0.001), and criminal behavior (p < 0.001) were found.
Conclusions
SBIRT was feasible to implement and the self-reported patient status at six months indicated significant improvements over baseline, for illicit drug use and heavy alcohol use, with functional domains improved, across a range of health care settings and a range of patients.
doi:10.1016/j.drugalcdep.2008.08.003
PMCID: PMC2760304  PMID: 18929451
services; treatment; prescription drug abuse; preventive medicine; marijuana; cocaine; heroin; methamphetamine; CPT® codes; primary health care; trauma centers
18.  Translation of a comprehensive health behavior intervention for women living with HIV: the SMART/EST Women's Program 
Translation of behavioral interventions into community settings for people living with HIV/AIDS can decrease the risk of comorbid conditions. This study was designed to determine whether a multiple health behavior intervention for women with HIV/AIDS could be effectively translated into community health centers (CHCs), delivered by CHC primary care staff. Health Resources and Services Administration-supported CHCs in Miami, FL, and the New York metropolitan area participated. Six health behavior domains were assessed at baseline, 6 months, and 12 months post-intervention: nutrition, physical activity, sexual risk behavior, alcohol use, drug use, and tobacco use. Behavioral outcomes were compared between research staff-led and CHC staff-led intervention groups. Research staff and CHC staff outcomes were similar for the majority of outcomes. Results indicate that complex, multicomponent behavioral interventions can be translated into community-based settings with existing CHC staff and can produce clinical effects similar to those achieved by research staff.
doi:10.1007/s13142-013-0213-4
PMCID: PMC3830012  PMID: 24294330
HIV/AIDS; Women; Translation; Behavioral intervention; Risk behavior; Effectiveness; Dissemination and implementation; Fidelity
19.  Impact of an informed choice invitation on uptake of screening for diabetes in primary care (DICISION): randomised trial 
Objective To compare the effect of an invitation promoting informed choice for screening with a standard invitation on attendance and motivation to engage in preventive action.
Design Randomised controlled trial.
Setting Four English general practices.
Participants 1272 people aged 40-69 years, at risk for diabetes, identified from practice registers using a validated risk score and invited to attend for screening.
Intervention Intervention was a previously validated invitation to inform the decision to attend screening, presenting diabetes as a serious potential problem, and providing details of possible costs and benefits of screening and treatment in text and pie charts. This was compared with a brief, standard invitation simply describing diabetes as a serious potential problem.
Main outcome measures The primary end point was attendance for screening. The secondary outcome measures were intention to make changes to lifestyle and satisfaction with decisions made among attenders.
Results The primary end point was analysed for all 1272 participants. 55.8% (353/633) of those in the informed choice group attended for screening, compared with 57.6% (368/639) in the standard invitation group (mean difference −1.8%, 95% confidence interval −7.3% to 3.6%; P=0.51). Attendance was lower among the more deprived group (most deprived third 47.5% v least deprived third 64.3%; P<0.001). Interaction between deprivation and effect of invitation type on attendance was not significant. Among attenders, intention to change behaviour was strong and unaffected by invitation type.
Conclusions Providing information to support choice did not adversely affect attendance for screening for diabetes. Those from more socially deprived groups were, however, less likely to attend, regardless of the type of invitation received. Further attention to invitation content alone is unlikely to achieve equity in uptake of preventive services.
Trial registration Current Controlled Trials ISRCTN 73125647.
doi:10.1136/bmj.c2138
PMCID: PMC2869404  PMID: 20466791
20.  Economic evaluation of cholesterol-related interventions in general practice. An appraisal of the evidence 
STUDY OBJECTIVE: To investigate and evaluate published data on cost effectiveness of cholesterol lowering interventions, and how this information could be interpreted in a rational approach of cholesterol management in general practice. DESIGN: A systematic review of the literature. SETTING: No restriction on setting. MATERIALS: Papers reporting on the cost effectiveness or cost utility of prevention of (recurrent) coronary heart disease by reduction of hypercholesterolaemia in adults. MAIN RESULTS: Thirty nine studies, most cost effectiveness analyses, were included. In 24 studies drug interventions only were analysed. Costs of screening to target cholesterol lowering interventions to persons with hypercholesterolaemia were considered in nine studies. Adjustments of the efficacy of the intervention for community effectiveness were described in seven studies. In four studies life years gained were adjusted for quality of life. Despite large variation in the outcomes, there is a constant tendency towards a less favourable cost effectiveness ratio for intervening in persons without coronary heart disease compared with persons with coronary heart disease and for women compared with men. CONCLUSIONS: There is lack of data on cost effectiveness of cholesterol lowering interventions in the general practice setting. The cost effectiveness of cholesterol lowering in general practice deteriorates when all relevant costs are taken into account and when efficacy is corrected for community effectiveness. Cholesterol lowering intervention is more cost effective in men compared with women and in patients with coronary heart disease compared with persons without coronary heart disease. Considerations from cost effectiveness analyses should be incorporated into the development and implementation of national cholesterol guidelines for general practitioners. Standardisation of cost effectiveness studies is important for future economic evaluations.
 
PMCID: PMC1756760  PMID: 10320860
21.  Screening and brief interventions for hazardous alcohol use in accident and emergency departments: a randomised controlled trial protocol 
Background
There is a wealth of evidence regarding the detrimental impact of excessive alcohol consumption on the physical, psychological and social health of the population. There also exists a substantial evidence base for the efficacy of brief interventions aimed at reducing alcohol consumption across a range of healthcare settings. Primary research conducted in emergency departments has reinforced the current evidence regarding the potential effectiveness and cost-effectiveness. Within this body of evidence there is marked variation in the intensity of brief intervention delivered, from very minimal interventions to more intensive behavioural or lifestyle counselling approaches. Further the majority of primary research has been conducted in single centre and there is little evidence of the wider issues of generalisability and implementation of brief interventions across emergency departments.
Methods/design
The study design is a prospective pragmatic factorial cluster randomised controlled trial. Individual Emergency Departments (ED) (n = 9) are randomised with equal probability to a combination of screening tool (M-SASQ vs FAST vs SIPS-PAT) and an intervention (Minimal intervention vs Brief advice vs Brief lifestyle counselling). The primary hypothesis is that brief lifestyle counselling delivered by an Alcohol Health Worker (AHW) is more effective than Brief Advice or a minimal intervention delivered by ED staff. Secondary hypotheses address whether short screening instruments are more acceptable and as efficient as longer screening instruments and the cost-effectiveness of screening and brief interventions in ED. Individual participants will be followed up at 6 and 12 months after consent. The primary outcome measure is performance using a gold-standard screening test (AUDIT). Secondary outcomes include; quantity and frequency of alcohol consumed, alcohol-related problems, motivation to change, health related quality of life and service utilisation.
Discussion
This paper presents a protocol for a large multi-centre pragmatic factorial cluster randomised trial to evaluate the effectiveness and cost-effectiveness of screening and brief interventions for hazardous alcohol users attending emergency departments.
Trial Registration
ISRCTN 93681536
doi:10.1186/1472-6963-9-114
PMCID: PMC2712466  PMID: 19575791
22.  Activating Seniors to Improve Chronic Disease Care: Results from a Pilot Intervention Study 
Objectives
Patient activation can improve health outcomes for chronic diseases that disproportionately affect the elderly. The present study evaluated the impact of an activation intervention delivered in community senior centers.
Participants
One hundred and sixteen senior participants.
Setting
Two Los Angeles community senior centers.
Intervention
Participants were invited to attend group screenings of video programs intended to inform and motivate self-management of chronic conditions common among seniors. Screenings were followed by moderated discussions reinforcing active patient participation in chronic disease management. Screenings were scheduled over the course of 12 weeks.
Design and Measures
One center was assigned by coin-toss to an encouragement condition, in which participants received a $50 gift card if they attended at least 3 group screenings. Participants in the non-encouraged center received no incentive for attendance. Validated study measures for patient activation, physical activity and health-related quality of life were completed at baseline, 12 weeks and 6 months following enrollment.
Results
Participants attending the encouraged senior center were more likely to attend 3 or more group screenings (77.8% vs. 47.2%, p=.001). At 6-month follow-up, participants from either center who attended 3 or more group screenings (n=74, 64%) reported significantly greater activation (p=.000), more minutes walking (p=.000) and engaging in vigorous physical activity (p=.006) and better health-related quality of life (SF-12 MCS: p=.000; SF-12 PCS: p=.002).
Conclusion
Delivering this pilot intervention in community senior centers is a potentially promising approach to activate seniors that warrants further investigation for improving chronic disease outcomes.
doi:10.1111/j.1532-5415.2010.02980.x
PMCID: PMC2955177  PMID: 20662953
Chronic diseases; patient activation; self-management
23.  The Recovery Spectrum 
Alcohol Research & Health  2011;33(4):371-379.
Recent innovations in alcohol-focused interventions are aimed at closing the gap between population need and the currently uncommon use of alcohol treatment services. Guided by population data showing the heterogeneity of alcohol problems and the occurrence of natural remissions from problem drinking without treatment, alcohol services have begun to expand beyond clinical treatment to offer the untreated majority of individuals with alcohol-related problems accessible, less-intensive services that use the tools of public health practice. These services often are opportunistic, meaning they can be provided in primary-care or other unspecialized health care or community settings. They also can be delivered by nonspecialists, or can be used by people themselves to address problems with alcohol without entering the health care system. This developing spectrum of services includes screening and brief interventions, guided self-change programs, and telehealth options that often are targeted and tailored for high-risk groups (e.g., college drinkers). Other efforts aimed at reducing barriers to care and increasing motivation to seek help have utilized individual, organizational, and public health strategies. Together, these efforts have potential for helping the treatment field reach people who have realized that they have a drinking problem but have not yet experienced the severe negative consequences that may eventually drive them to seek treatment. Although the evidence supporting several innovations in alcohol services is preliminary, some approaches are well established, and collectively they form an emerging continuum of care for alcohol problems aimed at increasing service availability and improving overall impact on population health.
PMCID: PMC3860536  PMID: 23580021
Alcohol use disorders; alcohol and other drugs recovery; treatment; health care delivery; health service; help-seeking behavior; high-risk groups; screening; brief interventions; guided self-change; telehealth; continuum of care
24.  Treatment adherence and facilitator characteristics in a community based pediatric weight control intervention 
Background
There is a pressing need to develop effective and broadly accessible interventions to address pediatric obesity. An important dimension in translating interventions to community settings is evaluating the fidelity with which the intended treatment is delivered and the level of facilitator needed to deliver the intervention with efficacy.
Purpose
The primary objectives of this study were to: 1) provide descriptive information regarding adherence to protocol and non-specific facilitator characteristics (e.g. interpersonal characteristics, group management skills) within the context of a community based pediatric weight control intervention delivered by paraprofessionals; and 2) examine the relationships among facilitator adherence and characteristics and rate of change in percent overweight demonstrated by youth over the course of the 24-week intervention.
Methods
The intervention was conducted between February and September of 2011. Children (6–16 years) and parents completed primary outcome measures at baseline, 12, and 24 weeks (i.e. end of treatment). A 2-part rating form was developed to assess facilitator adherence to weekly content and general provider characteristics at two different time points during the intervention.
Results
Youth participating in this study were on average 11.3 years old (SD = 2.8), with most being under the age of 13 years (74.2%). Over half were female (54.8%) and over two-thirds were White (68.4%). On average, facilitators adhered to 96.0% (SD = 5.2%) of the session content at Time 1 and 92.6% (SD = 6.8%) at Time 2. Higher Content Adherence at Time 1 and Time 2 were associated with greater loss in percent overweight.
Conclusions
Our data suggest that paraprofessionals without prior expertise in pediatric weight control can be trained to successfully deliver an intervention that is evidence based and incorporates behavioral and educational components. These findings need to be considered in light of some limitations, including the fact that facilitator domains were assessed with a modification of a standardized tool and we did not obtain inter-rater reliability of observations. These limitations not withstanding, investing time in training facilitators to adhere to a given protocol is critical and may be of higher priority than focusing on more general facilitator characteristics.
doi:10.1186/1479-5868-11-17
PMCID: PMC3926266  PMID: 24524280
Obesity; Pediatric; Intervention; Community; Facilitator
25.  An efficacy trial of brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial) 
BMC Nursing  2010;9:4.
Background
Lifestyle risk factors, in particular smoking, nutrition, alcohol consumption and physical inactivity (SNAP) are the main behavioural risk factors for chronic disease. Primary health care (PHC) has been shown to be an effective setting to address lifestyle risk factors at the individual level. However much of the focus of research to date has been in general practice. Relatively little attention has been paid to the role of nurses working in the PHC setting. Community health nurses are well placed to provide lifestyle intervention as they often see clients in their own homes over an extended period of time, providing the opportunity to offer intervention and enhance motivation through repeated contacts. The overall aim of this study is to evaluate the impact of a brief lifestyle intervention delivered by community nurses in routine practice on changes in clients' SNAP risk factors.
Methods/Design
The trial uses a quasi-experimental design involving four generalist community nursing services in NSW Australia. Services have been randomly allocated to an 'early intervention' group or 'late intervention' (comparison) group. 'Early intervention' sites are provided with training and support for nurses in identifying and offering brief lifestyle intervention for clients during routine consultations. 'Late intervention site' provide usual care and will be offered the study intervention following the final data collection point. A total of 720 generalist community nursing clients will be recruited at the time of referral from participating sites. Data collection consists of 1) telephone surveys with clients at baseline, three months and six months to examine change in SNAP risk factors and readiness to change 2) nurse survey at baseline, six and 12 months to examine changes in nurse confidence, attitudes and practices in the assessment and management of SNAP risk factors 3) semi-structured interviews/focus with nurses, managers and clients in 'early intervention' sites to explore the feasibility, acceptability and sustainability of the intervention.
Discussion
The study will provide evidence about the effectiveness and feasibility of brief lifestyle interventions delivered by generalist community nurses as part of routine practice. This will inform future community nursing practice and PHC policy.
Trial Registration
ACTRN12609001081202
doi:10.1186/1472-6955-9-4
PMCID: PMC2841173  PMID: 20175932

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