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1.  Screening and Brief Intervention for Drug Use in Primary Care 
JAMA  2014;312(5):502-513.
IMPORTANCE
The United States has invested substantially in screening and brief intervention for illicit drug use and prescription drug misuse, based in part on evidence of efficacy for unhealthy alcohol use. However, it is not a recommended universal preventive service in primary care because of lack of evidence of efficacy.
OBJECTIVE
To test the efficacy of 2 brief counseling interventions for unhealthy drug use (any illicit drug use or prescription drug misuse)—a brief negotiated interview (BNI) and an adaptation of motivational interviewing (MOTIV)—compared with no brief intervention.
DESIGN, SETTING, AND PARTICIPANTS
This 3-group randomized trial took place at an urban hospital-based primary care internal medicine practice; 528 adult primary care patients with drug use (Alcohol, Smoking, and Substance Involvement Screening Test [ASSIST] substance-specific scores of $4) were identified by screening between June 2009 and January 2012 in Boston, Massachusetts.
INTERVENTIONS
Two interventions were tested: the BNI is a 10- to 15-minute structured interview conducted by health educators; the MOTIV is a 30- to 45-minute intervention based on motivational interviewing with a 20- to 30-minute booster conducted by master’s-level counselors. All study participants received a written list of substance use disorder treatment and mutual help resources.
MAIN OUTCOMES AND MEASURES
Primary outcome was number of days of use in the past 30 days of the self-identified main drug as determined by a validated calendar method at 6 months. Secondary outcomes included other self-reported measures of drug use, drug use according to hair testing, ASSIST scores (severity), drug use consequences, unsafe sex, mutual help meeting attendance, and health care utilization.
RESULTS
At baseline, 63% of participants reported their main drug was marijuana, 19% cocaine, and 17% opioids. At 6 months, 98% completed follow-up. Mean adjusted number of days using the main drug at 6 months was 12 for no brief intervention vs 11 for the BNI group (incidence rate ratio [IRR], 0.97; 95% CI, 0.77-1.22) and 12 for the MOTIV group (IRR, 1.05; 95% CI, 0.84-1.32; P = .81 for both comparisons vs no brief intervention). There were also no significant effects of BNI or MOTIV on any other outcome or in analyses stratified by main drug or drug use severity.
CONCLUSIONS AND RELEVANCE
Brief intervention did not have efficacy for decreasing unhealthy drug use in primary care patients identified by screening. These results do not support widespread implementation of illicit drug use and prescription drug misuse screening and brief intervention.
TRIAL REGISTRATION
clinicaltrials.gov Identifier: NCT00876941
doi:10.1001/jama.2014.7862
PMCID: PMC4667772  PMID: 25096690
2.  How patients understand the term ‘nonmedical use’ of prescription drugs: insights from cognitive interviews 
Background
With rising rates of prescription drug abuse and associated overdose deaths, there is great interest in having accurate and efficient screening tools that identify nonmedical use of prescription drugs in health care settings. We sought to gain a better understanding of how patients interpret questions about misuse of prescription drugs, with the goal of improving the accuracy and acceptability of instruments intended for use in primary care.
Methods
A total of 27 English speaking adult patients were recruited from an urban safety net primary care clinic to complete a cognitive interview about a four-item screening questionnaire for tobacco, alcohol, illicit drugs, and misuse of prescription drugs. Detailed field notes were analyzed for overall comprehension of the screening items on illicit drug use and prescription drug misuse, the accuracy with which participants classified drugs into these categories, and whether the screening response correctly captured the participant’s substance use behavior.
Results
Based on initial responses to the screening items, 6 (22%) participants screened positive for past year prescription drug misuse, and 8 (30%) for illicit drug use. The majority (26/27) of participants correctly interpreted the item on illicit drug use, and appropriately classified drugs in this category. Eleven (41%) participants had errors in their understanding of the prescription drug misuse item. The most common error was including use of medications without abuse potential as misuse. All cases of misunderstanding prescription drug misuse occurred among participants who screened negative for illicit drug use.
Conclusions
Our results suggest that terminology used to describe misuse of prescription medications may be misunderstood by many primary care patients, particularly those who do not use illicit drugs. Failure to improve upon the language used to describe prescription drug misuse in screening questionnaires intended for use in medical settings could potentially lead to high rates of false positive results.
doi:10.1080/08897077.2013.789463
PMCID: PMC3942803  PMID: 24588288
Screening; Prescription drug misuse
3.  Cost-Effectiveness of Rapid Syphilis Screening in Prenatal HIV Testing Programs in Haiti 
PLoS Medicine  2007;4(5):e183.
Background
New rapid syphilis tests permit simple and immediate diagnosis and treatment at a single clinic visit. We compared the cost-effectiveness, projected health outcomes, and annual cost of screening pregnant women using a rapid syphilis test as part of scaled-up prenatal testing to prevent mother-to-child HIV transmission in Haiti.
Methods and Findings
A decision analytic model simulated health outcomes and costs separately for pregnant women in rural and urban areas. We compared syphilis syndromic surveillance (rural standard of care), rapid plasma reagin test with results and treatment at 1-wk follow-up (urban standard of care), and a new rapid test with immediate results and treatment. Test performance data were from a World Health Organization–Special Programme for Research and Training in Tropical Diseases field trial conducted at the GHESKIO Center Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes in Port-au-Prince. Health outcomes were projected using historical data on prenatal syphilis treatment efficacy and included disability-adjusted life years (DALYs) of newborns, congenital syphilis cases, neonatal deaths, and stillbirths. Cost-effectiveness ratios are in US dollars/DALY from a societal perspective; annual costs are in US dollars from a payer perspective. Rapid testing with immediate treatment has a cost-effectiveness ratio of $6.83/DALY in rural settings and $9.95/DALY in urban settings. Results are sensitive to regional syphilis prevalence, rapid test sensitivity, and the return rate for follow-up visits. Integrating rapid syphilis testing into a scaled-up national HIV testing and prenatal care program would prevent 1,125 congenital syphilis cases and 1,223 stillbirths or neonatal deaths annually at a cost of $525,000.
Conclusions
In Haiti, integrating a new rapid syphilis test into prenatal care and HIV testing would prevent congenital syphilis cases and stillbirths, and is cost-effective. A similar approach may be beneficial in other resource-poor countries that are scaling up prenatal HIV testing.
Analyzing data from Haiti, Bruce Schackman and colleagues report that scale-up of prenatal HIV testing programs provides a cost-effective opportunity to prevent congenital syphilis through rapid testing.
Editors' Summary
Background.
Congenital syphilis (syphilis that is passed on from a woman infected with the disease to her unborn baby) is a major preventable public health problem. Around half of all pregnancies among women infected with syphilis result in stillbirth or death of the baby shortly after birth. However, it should be possible to reduce the health burden of congenital syphilis if infections among pregnant women could be quickly and accurately diagnosed. In resource-poor countries, many syphilis infections go undiagnosed, because the tests that are normally used involve sending samples away to a laboratory for processing. This means that the diagnosis can only be confirmed, and treatment started, at the next available visit. As a result, there is a delay in starting antibiotic treatment, and some women may never receive their intended treatment at all if they cannot return for their follow-up visit. However, new tests are available that don't involve cold storage of reagents or electrical equipment, and these can be used to give an immediate result about syphilis infection even in rural or resource-poor settings. Currently, global initiatives are underway to ensure many more pregnant women are tested for HIV and to reduce the risk of HIV being passed on from a woman to her baby. These initiatives could provide an important opportunity for carrying out widespread immediate screening for syphilis during pregnancy as well. Such screening might then help reduce infant deaths substantially.
Why Was This Study Done?
Field trials evaluating rapid syphilis tests have already been carried out by the World Health Organization's Special Programme for Research and Training in Tropical Diseases. One such trial, carried out in Port-au-Prince, Haiti, evaluated the success of three different rapid syphilis tests as compared to two “gold standard” tests (older tests that are generally considered reliable, but which don't give an immediate result). These researchers wanted to use data from these trials to compare costs and predicted health outcomes of including different types of syphilis screening as part of scaled-up prenatal care. Specifically, the researchers wanted to find out whether including rapid syphilis testing as part of universal prenatal care would be cost-effective and whether it would reduce the rate of stillbirths and congenital syphilis.
What Did the Researchers Do and Find?
This research was based on data from the field trials previously carried out in Haiti. The data from these trials were used to create a model comparing three different strategies for screening pregnant women for syphilis infections. The three strategies were as follows: checking for the symptoms of syphilis (assumed to be the standard of care in rural areas); standard testing for antibody response to the syphilis bacterium, after which treatment can be provided at follow-up a week later (assumed to be the standard of care in urban areas); and, finally, rapid testing that gives an immediate result. For each strategy, the researchers predicted what the health outcomes would be. These outcomes are summarized in “disability-adjusted life years” (DALYs) that reflect the number of years of healthy life lost due to congenital syphilis among newborn babies, the number of stillbirths, and the number of neonatal deaths. Cost-effectiveness of each strategy was also worked out by dividing the additional costs of testing and treatment for each strategy by the number of DALYs avoided using that screening method compared to the next most expensive alternative. Under the model, urban and rural settings were looked at separately. Immediate testing was more expensive than either standard testing or checking for symptoms, but emerged as more cost-effective than standard testing in rural settings; the immediate test would cost an additional $7–$10 per disability-adjusted life year compared to the current rural or urban standard of care. The researchers predicted that if immediate syphilis testing were provided to all pregnant women in Haiti who currently have access to prenatal care, over 1,000 congenital syphilis cases would be avoided, along with over 1,000 stillbirths and neonatal deaths, at a yearly cost of $525,000.
What Do These Findings Mean?
This model suggests that including rapid syphilis testing as part of current global initiatives for preventing mother-to-child transmission of HIV could substantially reduce infant deaths. The strategy is also likely to be cost-effective.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040183.
MedlinePlus encyclopedia entry on congenital syphilis
Information from the World Health Organization about congenital syphilis, including information about screening programs and new screening tests
A report is also available from the Special Programme for Research and Training in Tropical Diseases regarding rapid syphilis tests
AVERT, an international AIDS charity, provides information about preventing mother-to-child transmission of HIV
doi:10.1371/journal.pmed.0040183
PMCID: PMC1880854  PMID: 17535105
4.  Barriers and facilitators of hepatitis C screening among people who inject drugs: a multi-city, mixed-methods study 
Background
People who inject drugs (PWID) are at high risk of contracting and transmitting and hepatitis C virus (HCV). While accurate screening tests and effective treatment are increasingly available, prior research indicates that many PWID are unaware of their HCV status.
Methods
We examined characteristics associated with HCV screening among 553 PWID utilizing a free, multi-site syringe exchange program (SEP) in 7 cities throughout Wisconsin. All participants completed an 88-item, computerized survey assessing past experiences with HCV testing, HCV transmission risk behaviors, and drug use patterns. A subset of 362 clients responded to a series of open-ended questions eliciting their perceptions of barriers and facilitators to screening for HCV. Transcripts of these responses were analyzed qualitatively using thematic analysis.
Results
Most respondents (88%) reported receiving a HCV test in the past, and most of these (74%) were tested during the preceding 12 months. Despite the availability of free HCV screening at the SEP, fewer than 20% of respondents had ever received a test at a syringe exchange site. Clients were more likely to receive HCV screening in the past year if they had a primary care provider, higher educational attainment, lived in a large metropolitan area, and a prior history of opioid overdose. Themes identified through qualitative analysis suggested important roles of access to medical care and prevention services, and nonjudgmental providers.
Conclusions
Our results suggest that drug-injecting individuals who reside in non-urban settings, who have poor access to primary care, or who have less education may encounter significant barriers to routine HCV screening. Expanded access to primary health care and prevention services, especially in non-urban areas, could address an unmet need for individuals at high risk for HCV.
doi:10.1186/1477-7517-11-1
PMCID: PMC3896714  PMID: 24422784
Hepatitis C; Screening; Injection drug use; Stigma; Health care access
5.  A Randomized Controlled Trial Testing the Efficacy of a Brief Cannabis Universal Prevention Program among Adolescents in Primary Care 
Addiction (Abingdon, England)  2014;109(5):786-797.
Aims
To examine the efficacy of a brief intervention delivered by a therapist (TBI) or a computer (CBI), in preventing cannabis use among adolescents in urban primary care clinics.
Design
A randomized controlled trial comparing: CBI and TBI versus control.
Setting
Urban primary care clinics in the United States.
Participants
Research staff recruited 714 adolescents (ages 12-18) who reported no lifetime cannabis use on a screening survey for this study, which included a baseline survey, randomization (stratified by gender and grade) to conditions (control; CBI; TBI), and 3, 6, and 12 month assessments.
Measurements
Using an intent to treat approach, primary outcomes were cannabis use (any, frequency); secondary outcomes included frequency of other drug use, severity of alcohol use, and frequency of delinquency (among 85% completing follow-ups).
Findings
Compared with controls, CBI participants had significantly lower rates of any cannabis use over 12 months (24.2%, 16.8%, respectively, p<.05), frequency of cannabis use at 3 and 6 months (p<.05) and other drug use at 3 months (p<.01). Compared with controls, TBI participants did not differ in cannabis use or frequency, but had significantly less other drug use at 3 months (p<.05), alcohol use at 6 months (p<.01), and delinquency at 3 months (p<.01).
Conclusions
Among adolescents in urban primary care in the United States, a computer brief intervention appeared to prevent and reduce cannabis use. Both computer and therapist delivered brief interventions appeared to have small effects in reducing other risk behaviors, but these dissipated over time.
doi:10.1111/add.12469
PMCID: PMC3984620  PMID: 24372937
6.  Assault and Mental Disorders: A Cross-Sectional Study of Urban Adult Primary Care Patients 
Objective
This study estimated the strength of associations between self-reported assault and psychiatric disorders among low-income, urban primary care patients who were predominantly female.
Methods
A sample of adult patients who consecutively presented at an urban primary care practice completed the Life Events Checklist (N=1,157). They were also screened for current major depression, panic disorder, generalized anxiety disorder, and substance use disorders with the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire; for bipolar disorder with the Mood Disorder Questionnaire; and for posttraumatic stress disorder (PTSD) with the PTSD Checklist–Civilian Version. A total of 977 of the respondents reported whether they had ever experienced an assault. Logistic regression was used to model associations between self-reported assault and screen status, controlling for relevant sociodemographic and clinical characteristics.
Results
Twenty-five percent of study participants endorsed a history of physical or sexual assault. Compared with patients without a history of assault, patients with a history of assault had significantly greater odds of screening positive for PTSD (odds ratio [OR]=1.97, 95% confidence interval [CI]=1.19–3.25), alcohol use disorder (OR=2.17, CI=1.07–4.41), and drug use disorder (OR=3.38, CI=1.14–9.98).
Conclusion
A history of assault was related to risk of screening positive for PTSD and a substance use disorder. These findings support assessment of trauma history among low-income primary care patients.
doi:10.1176/appi.ps.61.10.1018
PMCID: PMC3630070  PMID: 20889641
7.  A cohort study comparing cardiovascular risk factors in rural Māori, urban Māori and non-Māori communities in New Zealand 
BMJ Open  2012;2(3):e000799.
Objectives
To understand health disparities in cardiovascular disease (CVD) in the indigenous Māori of New Zealand, diagnosed and undiagnosed CVD risk factors were compared in rural Māori in an area remote from health services with urban Māori and non-Māori in a city well served with health services.
Design
Prospective cohort study.
Setting
Hauora Manawa is a cohort study of diagnosed and previously undiagnosed CVD, diabetes and risk factors, based on random selection from electoral rolls of the rural Wairoa District and Christchurch City, New Zealand.
Participants
Screening clinics were attended by 252 rural Māori, 243 urban Māori and 256 urban non-Māori, aged 20–64 years.
Main outcome measures
The study documented personal and family medical history, blood pressure, anthropometrics, fasting lipids, insulin, glucose, HbA1c and urate to identify risk factors in common and those that differ among the three communities.
Results
Mean age (SD) was 45.7 (11.5) versus 42.6 (11.2) versus 43.6 (11.5) years in rural Māori, urban Māori and non-Māori, respectively. Age-adjusted rates of diagnosed cardiac disease were not significantly different across the cohorts (7.5% vs 5.8% vs 2.8%, p=0.073). However, rural Māori had significantly higher levels of type-2 diabetes (10.7% vs 3.7% vs 2.4%, p<0.001), diagnosed hypertension (25.0% vs 14.9% vs 10.7%, p<0.001), treated dyslipidaemia (15.7% vs 7.1% vs 2.8%, p<0.001), current smoking (42.8% vs 30.5% vs 15.2%, p<0.001) and age-adjusted body mass index (30.7 (7.3) vs 29.1 (6.4) vs 26.1 (4.5) kg/m2, p<0.001). Similarly high rates of previously undocumented elevated blood pressure (22.2% vs 23.5% vs 17.6%, p=0.235) and high cholesterol (42.1% vs 54.3% vs 42.2%, p=0.008) were observed across all cohorts.
Conclusions
Supporting integrated rural healthcare to provide screening and management of CVD risk factors would reduce health disparities in this indigenous population.
Article summary
Article focus
The indigenous Māori of New Zealand have high rates of CVD mortality and morbidity. Current data on the key risk factors underlying this ethnic disparity mostly come from national surveys relying on self-reported diagnoses or have been collected in New Zealand's largest urban centre, Auckland City.
This is the first study to screen CVD and associated risk factors concurrently between rural Māori residing in an area remote from health services (Wairoa District), urban Māori in a city well served with secondary and tertiary health services (Christchurch City) and an urban non-Māori cohort.
Key messages
We found that rural Māori had higher levels of obesity, smoking, hypertension, dyslipidaemia, diabetes mellitus type 2 and hyperuriaemia than either urban Māori or non-Māori. Thus, national health surveys and data collected in large urban centres may significantly underestimate the burden of CVD risk carried by rural Māori.
Public health initiatives to reduce rates of smoking among rural Māori, along with enhanced implementation of CVD screening in primary care and more intensive clinical management of hypertension, dyslipidaemia and hypeuricaemia would help reduce cardiovascular health disparities in the New Zealand indigenous population.
Strengths and limitations of this study
This study was able to determine current levels of both diagnosed and undiagnosed risk factors within these communities by conducting CVD screening clinics in sectors of the community that are often hard to reach. The findings of this study are limited by the relatively small cohort sizes and lack of a rural non-Māori comparator cohort.
doi:10.1136/bmjopen-2011-000799
PMCID: PMC3378934  PMID: 22685219
8.  Alcohol misuse 
BMJ Clinical Evidence  2011;2011:1017.
Introduction
Alcohol use is a leading cause of mortality and morbidity internationally, and is ranked by the World Health Organization (WHO) as one of the top 5 risk factors for disease burden. Without treatment, approximately 16% of hazardous or harmful alcohol users will progress to more dependent patterns of alcohol consumption. This review covers interventions in hazardous or harmful, but not dependent, alcohol users.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions in hazardous or harmful drinkers in the primary-care setting? What are the effects of interventions in hazardous or harmful drinkers in the emergency-department setting? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 21 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review, we present information relating to the effectiveness and safety of the following interventions in primary care and in emergency departments: brief intervention (single or multiple session), universal screening plus brief interventions, and targeted screening plus brief interventions.
Key Points
Alcohol use is a leading cause of mortality and morbidity internationally, and is ranked by the WHO as one of the top 5 risk factors for disease burden. Without treatment, approximately 16% of hazardous or harmful alcohol users will progress to more dependent patterns of alcohol consumption.
This review covers interventions in hazardous or harmful (but not dependent) alcohol users. Hazardous alcohol consumption is defined as a pattern of alcohol consumption that increases the individual's risk of alcohol-related harm, but is not currently causing alcohol-related harm.Harmful alcohol consumption is a pattern of consumption likely to have already led to alcohol-related harm.
Single- or multiple-session brief intervention reduces alcohol consumption over 1 year in hazardous drinkers treated in the primary-care setting, but we don't know how it affects mortality.
Brief intervention (single or multiple session) is also effective at reducing alcohol consumption in people treated in the emergency department, although the evidence is not as strong.
Adding universal screening to brief intervention enhances its benefits when given in primary care. We found insufficient RCT evidence to assess whether universal screening and brief intervention is any more effective than usual care in emergency departments.We don't know whether targeted screening is effective, as we found no RCT evidence assessing its use in primary or emergency care.
PMCID: PMC3275317  PMID: 21426592
9.  Inventory of Drug Samples in a Health Care Institution 
Background:
Few data exist on the presence of drug samples in health care facilities. Although the use of drug samples has potential benefits, this practice is also controversial, as it can contribute to non-optimal drug use. The objective of this study was to evaluate the inventory of drug samples in a health care institution and to determine compliance with existing policies and procedures.
Methods:
This descriptive observational study was conducted in a university hospital centre from October 18 to November 1, 2007. A standardized data collection form was used for a physical inventory, which was intended to identify all drug samples available in the institution. The following information was recorded: number of locations where drug samples were found, primary patient care activity performed at each location, number of storage areas in the location, type of storage, presence of a lock, location of the key (if a lock was present), medical specialty, number of physicians and nurses likely to use the samples, reasons given for handing out samples, presence of a designated person to manage the samples, physical inventory (i.e., various details for each distribution unit), and declaration of samples to the pharmacy department. The inventory was conducted by 2 research assistants during day shifts.
Results:
A total of 84 locations were included in the inventory, and drug samples were found in 21 locations (with a total of 31 storage areas). All of the locations were intended for ambulatory patients (outpatient clinics and day centres). No drug samples were found in inpatient care units. The drug samples, which came from 62 different pharmaceutical companies, represented a total of 159 generic entities and 266 different brands. Of the distribution units for drug samples that were identified during this inventory, 59% were not on the hospital’s local formulary. Furthermore, only 3.5% of the distribution units had been declared to the pharmacy department, in accordance with established policy. The sample distribution units, including expired units, totalled 78 955 doses, with a total value of Can$48 783 (based on unit prices in effect in October 2007).
Conclusion:
This study presents an inventory of drug samples in an urban health care institution and reports compliance with the institution’s policies and procedures regarding drug samples. Samples were found only in outpatient clinics and represented 2.4 times the hospital’s floor stock of medications. Most of the samples inventoried were not listed on the hospital’s formulary. It appears that the use of drug samples is underestimated in hospital settings. Further studies are needed to evaluate the importance of drug samples and the risks associated with their use.
PMCID: PMC2826967  PMID: 22478908
drugs samples; health care facilities; inventory management; échantillons de médicaments; établissements de santé; gestion des stocks
10.  Do place of residence and ethnicity affect health services utilization? evidence from greece 
Background
Equal utilization of health services for equal need, is one of the main targets for public health systems. Given the public-private structure of the Greek NHS, the main aim of the study was to investigate the impact of underlying factors, such as health care needs, socio-demographic characteristics and ethnicity, on the utilization of primary and hospital health care in an urban and rural population of the Greek region, Thessaly.
Methods
A cross-sectional study was carried out in 2006 in Thessaly, a Greek region of Central Greece, in a representative sample of 1372 individuals (18+ years old, response rate 91.4%) via face-to-face interview. Health care needs were determined by self-perceived health status estimated by the SF-36 Health Survey, using the summary scores of physical and mental health. The utilization of primary care was measured by last month visits to 1) primary public services and 2) private practitioners visits and utilization of secondary care was measured by past year visits to 3) public hospital emergency departments and 4) admissions to public hospitals. Multivariable stepwise logistic regression analysis was applied in the whole sample and separately for the urban and rural population, in order to determine the predictors of health services utilization. Statistical significance was determined with a p value < 0.05.
Results
Health care needs were the most significant determinants of primary and secondary health services utilization in both the urban and rural areas. Poor physical and mental health was associated with higher likelihood of use. In the urban areas middle-aged, elderly and Greeks were more likely to use primary health services, whereas primary education was associated with more visits to the emergency departments. Wealthier individuals were two times more likely to be admitted to hospitals. Individuals from the rural areas with university education visited more the public primary services, while wealthier individuals visited more the private practitioners. Immigrants had a higher likelihood of visiting emergency departments.
Conclusions
Although health care needs were the main determinant of health services utilization in both the urban and rural population, socio-economic and ethnic differences also seem to contribute to the inequities observed in some types of health services use, favouring the better-off. Such findings provide important information to policy makers, which attempt to reduce inequalities in health care according to place of residence and ethnicity.
doi:10.1186/1475-9276-10-16
PMCID: PMC3107789  PMID: 21521512
11.  Improving the outcomes of primary care attenders with common mental disorders in developing countries: a cluster randomized controlled trial of a collaborative stepped care intervention in Goa, India 
Trials  2008;9:4.
Background and Objective
Common mental disorders (CMD) are a leading global burden of disease. Up to 30% of primary care attenders suffer from these disorders but most do not receive evidence-based drug or psychological treatments. There are no trials of interventions which attempt to integrate these treatments into routine primary care in developing countries. The aims of this trial (the MANAS Project) are to evaluate the clinical and cost-effectiveness of a collaborative stepped-care intervention for the treatment of CMD in India.
Study Design
A cluster randomized controlled trial will be implemented in the state of Goa, on the west coast of India. Twenty-four primary care facilities, 12 from the government sector and 12 from the private sector, will be enrolled in two consecutive phases. For each sector, facilities will be randomly allocated within strata defined by urban/rural location, population size and presence of a visiting psychiatrist. Facilities will be randomly allocated to receive the collaborative stepped care intervention or the enhanced usual care control intervention. Both arms share two components of the intervention, viz., routine screening, and in the government clinics provision of antidepressants. In addition, the collaborative stepped care arm also provides a range of psychosocial treatments delivered by a specially trained Health Counselor, and supervision by a visiting Psychiatrist. A total of 3600 primary care attenders who are detected to suffer from a CMD based on a validated screening questionnaire will be recruited. The primary outcome is the proportion of subjects who recover from an ICD10 defined CMD at baseline by 6 months. Additional endpoints at 2 and 12 months will assess the speed and sustainability of achieving the primary outcomes. Other outcomes will include recovery from ICD10 defined depression and incidence of ICD-10 among individuals who were sub-threshold cases at baseline. Economic and disability outcomes will be assessed to estimate incremental cost-effectiveness ratios.
Implications
This will be the first trial of the effectiveness of a complex intervention aiming to integrate efficacious treatments for CMD into routine primary care in a developing country. If effective, its findings will have relevance to policy makers who wish to scale up treatments for CMD in primary care across the world, but mostly in those countries where specialist mental health services are few.
Study Registration
The MANAS project is registered through the National Institutes of Health sponsored clinical trials registry and has been assigned the identifier: NCT00446407
doi:10.1186/1745-6215-9-4
PMCID: PMC2265673  PMID: 18221516
12.  Recognizing Intimate Partner Violence in Primary Care: Western Cape, South Africa 
PLoS ONE  2012;7(1):e29540.
Introduction
Interpersonal violence in South Africa is the second highest contributor to the burden of disease after HIV/AIDS and 62% is estimated to be from intimate partner violence (IPV). This study aimed to evaluate how women experiencing IPV present in primary care, how often IPV is recognized by health care practitioners and what other diagnoses are made.
Methods
At two urban and three rural community health centres, health practitioners were trained to screen all women for IPV over a period of up to 8 weeks. Medical records of 114 thus identified women were then examined and their reasons for encounter (RFE) and diagnoses over the previous 2-years were coded using the International Classification of Primary Care. Three focus group interviews were held with the practitioners and interviews with the facility managers to explore their experience of screening.
Results
IPV was previously recognized in 11 women (9.6%). Women presented with a variety of RFE that should raise the index of suspicion for IPV– headache, request for psychiatric medication, sleep disturbance, tiredness, assault, feeling anxious and depressed. Depression was the commonest diagnosis. Interviews identified key issues that prevented health practitioners from screening.
Conclusion
This study demonstrated that recognition of women with IPV is very low in South African primary care and adds useful new information on how women present to ambulatory health services. These findings offer key cues that can be used to improve selective case finding for IPV in resource-poor settings. Universal screening was not supported by this study.
doi:10.1371/journal.pone.0029540
PMCID: PMC3252321  PMID: 22242173
13.  Urban-rural inequality regarding drug prescriptions in primary care facilities – a pre-post comparison of the National Essential Medicines Scheme of China 
Objective
To assess the impact of the National Essential Medicines Scheme (NEMS) with respect to urban-rural inequalities regarding drug prescriptions in primary care facilities.
Methods
A stratified two-stage random sampling strategy was used to sample 23,040 prescriptions from 192 primary care facilities from 2009 to 2010. Difference-in-Difference (DID) analyses were performed to test the association between NEMS and urban-rural gaps in prescription patterns. Between-Group Variance and Theil Index were calculated to measure urban-rural absolute and relative disparities in drug prescriptions.
Results
The use of the Essential Medicines List (EML) achieved a compliance rate of up to 90 % in both urban and rural facilities. An overall reduction of average prescription cost improved economic access to drugs for patients in both areas. However, we observed an increased urban-rural disparity in average expenditure per prescription. The rate of antibiotics and glucocorticoids prescription remained high, despite a reduced disparity between urban and rural facilities. The average incidence of antibiotic prescription increased slightly in urban facilities (62 to 63 %) and reduced in rural facilities (67 % to 66 %). The urban-rural disparity in the use of parenteral administration (injections and infusions) increased, albeit at a high level in both areas (44 %-52 %).
Conclusion
NEMS interventions are effective in reducing the overall average prescription costs. Despite the increased use of the EML, indicator performances with respect to rational drug prescribing and use remain poor and exceed the WHO/INRUD recommended cutoff values and worldwide benchmarks. There is an increased gap between urban and rural areas in the use of parenteral administration and expenditure per prescription.
doi:10.1186/s12939-015-0186-7
PMCID: PMC4518678  PMID: 26219841
Primary health care; Physician’s practice patterns; Essential medicines; Inequalities; China
14.  Primary care and youth mental health in Ireland: qualitative study in deprived urban areas 
BMC Family Practice  2013;14:194.
Background
Mental disorders account for six of the 20 leading causes of disability worldwide with a very high prevalence of psychiatric morbidity in youth aged 15–24 years. However, healthcare professionals are faced with many challenges in the identification and treatment of mental and substance use disorders in young people (e.g. young people’s unwillingness to seek help from healthcare professionals, lack of training, limited resources etc.) The challenge of youth mental health for primary care is especially evident in urban deprived areas, where rates of and risk factors for mental health problems are especially common. There is an emerging consensus that primary care is well placed to address mental and substance use disorders in young people especially in deprived urban areas. This study aims to describe healthcare professionals’ experience and attitudes towards screening and early intervention for mental and substance use disorders among young people (16–25 years) in primary care in deprived urban settings in Ireland.
Methods
The chosen method for this qualitative study was inductive thematic analysis which involved semi-structured interviews with 37 healthcare professionals from primary care, secondary care and community agencies at two deprived urban centres.
Results
We identified three themes in respect of interventions to increase screening and treatment: (1) Identification is optimised by a range of strategies, including raising awareness, training, more systematic and formalised assessment, and youth-friendly practices (e.g. communication skills, ensuring confidentiality); (2) Treatment is enhanced by closer inter-agency collaboration and training for all healthcare professionals working in primary care; (3) Ongoing engagement is enhanced by motivational work with young people, setting achievable treatment goals, supporting transition between child and adult mental health services and recognising primary care’s longitudinal nature as a key asset in promoting treatment engagement.
Conclusions
Especially in deprived areas, primary care is central to early intervention for youth mental health. Identification, treatment and continuing engagement are likely to be enhanced by a range of strategies with young people, healthcare professionals and systems. Further research on youth mental health and primary care, including qualitative accounts of young people’s experience and developing complex interventions that promote early intervention are priorities. (350 words)
doi:10.1186/1471-2296-14-194
PMCID: PMC3880165  PMID: 24341616
Young people; Urban deprivation; Mental health; Substance use; Primary care; General practice
15.  Trauma exposure and posttraumatic stress disorder among primary care patients with bipolar spectrum disorder 
Bipolar disorders  2008;10(4):503-510.
Objective
To examine relationships between exposure to trauma, bipolar spectrum disorder (BD) and posttraumatic stress disorder (PTSD) in a sample of primary care patients.
Methods
A systematic sample (n = 977) of adult primary care patients from an urban general medicine practice were interviewed with measures including the Mood Disorders Questionnaire, the PTSD Checklist–Civilian Version, and the Medical Outcomes Study 12-Item Short Form Health Survey.
Results
Compared with patients who screened negative for BD (n = 881), those who screened positive (n = 96) were 2.6 times [95% confidence interval (CI): 1.6–4.2] as likely to report physical or sexual assault, and 2.9 times (95% CI: 1.6–5.1) as likely to screen positive for current PTSD. Among those screening positive for BD, comorbid PTSD was associated with significantly worse social functioning. These results controlled for selected background characteristics, current major depressive episode, and current alcohol/drug use disorder.
Conclusion
In an urban general medicine setting, trauma exposure was related to BD, and the frequency of PTSD among patients with BD appears to be common and clinically significant. These results suggest an unmet need for mental health care in this specific population and are especially important in view of available treatments for BD and PTSD.
doi:10.1111/j.1399-5618.2008.00589.x
PMCID: PMC3633108  PMID: 18452446
bipolar disorder; posttraumatic stress disorder; primary care; trauma exposure
16.  Population based prostate cancer screening in north Mexico reveals a high prevalence of aggressive tumors in detected cases 
BMC Cancer  2009;9:91.
Background
Prostate Cancer (PCa) is the second most frequent neoplasia in men worldwide. Previous reports suggest that the prevalence of PCa in Hispanic males is lower than in Africans (including communities with African ancestry) and Caucasians, but higher than in Asians. Despite these antecedents, there are few reports of open population screenings for PCa in Latin American communities. This article describes the results of three consecutive screenings in the urban population of Monterrey, Mexico.
Methods
After receiving approval from our University Hospital's Internal Review Board (IRB), the screening was announced by radio, television, and press, and it was addressed to male subjects over 40 years old in general. Subjects who consented to participate were evaluated at the primary care clinics of the University Health Program at UANL, in the Metropolitan area of Monterrey. Blood samples were taken from each subject for prostate specific antigen (PSA) determination; they underwent a digital rectal examination (DRE), and were subsequently interviewed to obtain demographic and urologic data. Based on the PSA (>4.0 ng/ml) and DRE results, subjects were appointed for transrectal biopsy (TRB).
Results
A total of 973 subjects were screened. Prostate biopsy was recommended to 125 men based on PSA values and DRE results, but it was performed in only 55 of them. 15 of these biopsied men were diagnosed with PCa, mostly with Gleason scores ≥ 7.
Conclusion
Our results reflect a low prevalence of PCa in general, but a high occurrence of high grade lesions (Gleason ≥ 7) among patients that resulted positive for PCa. This observation remarks the importance of the PCa screening programs in our Mexican community and the need for strict follow-up campaigns.
doi:10.1186/1471-2407-9-91
PMCID: PMC2666762  PMID: 19317909
17.  The Health System and Population Health Implications of Large-Scale Diabetes Screening in India: A Microsimulation Model of Alternative Approaches 
PLoS Medicine  2015;12(5):e1001827.
Background
Like a growing number of rapidly developing countries, India has begun to develop a system for large-scale community-based screening for diabetes. We sought to identify the implications of using alternative screening instruments to detect people with undiagnosed type 2 diabetes among diverse populations across India.
Methods and Findings
We developed and validated a microsimulation model that incorporated data from 58 studies from across the country into a nationally representative sample of Indians aged 25–65 y old. We estimated the diagnostic and health system implications of three major survey-based screening instruments and random glucometer-based screening. Of the 567 million Indians eligible for screening, depending on which of four screening approaches is utilized, between 158 and 306 million would be expected to screen as “high risk” for type 2 diabetes, and be referred for confirmatory testing. Between 26 million and 37 million of these people would be expected to meet international diagnostic criteria for diabetes, but between 126 million and 273 million would be “false positives.” The ratio of false positives to true positives varied from 3.9 (when using random glucose screening) to 8.2 (when using a survey-based screening instrument) in our model. The cost per case found would be expected to be from US$5.28 (when using random glucose screening) to US$17.06 (when using a survey-based screening instrument), presenting a total cost of between US$169 and US$567 million. The major limitation of our analysis is its dependence on published cohort studies that are unlikely fully to capture the poorest and most rural areas of the country. Because these areas are thought to have the lowest diabetes prevalence, this may result in overestimation of the efficacy and health benefits of screening.
Conclusions
Large-scale community-based screening is anticipated to produce a large number of false-positive results, particularly if using currently available survey-based screening instruments. Resource allocators should consider the health system burden of screening and confirmatory testing when instituting large-scale community-based screening for diabetes.
Sanjay Basu and colleagues estimate the benefits and costs of scaling up survey- or glucometer-based diabetes screening across India’s diverse populations.
Editors' Summary
Background
Worldwide, 387 million people have diabetes, a chronic condition characterized by high levels of glucose (sugar) in the blood. Blood sugar levels are usually controlled by insulin, a hormone released by the pancreas after meals. In people with type 2 diabetes (the most common type of diabetes), blood sugar control fails because the fat and muscle cells that normally respond to insulin by removing excess sugar from the blood become less responsive to insulin. Risk factors for diabetes include being overweight, having a large waist, being physically inactive, and having a family history of diabetes. The symptoms of diabetes, which develop slowly, include excessive urination at night and unexplained weight loss. Type 2 diabetes can usually be controlled initially with diet and exercise and with antidiabetic drugs such as metformin and sulfonylureas, but many patients eventually need insulin injections. Long-term complications of diabetes, which include an increased risk of heart disease and stroke, reduce the life expectancy of people with diabetes by about 10 years compared to people without diabetes.
Why Was This Study Done?
Diabetes is becoming increasing common, particularly in rapidly developing countries, but most people with diabetes in these countries are unaware that they have the condition. Because the risk of developing diabetic complications is reduced by careful blood sugar control, it is important to identify and treat anyone who has diabetes as early as possible. Some rapidly developing countries are therefore beginning to develop systems for large-scale community-based screening for diabetes (even though the UK has recently decided against such screening). In India, for example, more than 53 million adults living in rural and urban communities have already been screened using either questionnaires designed to provide a risk score (survey-based screening) or random blood glucose testing (glucometer-based screening). People who are identified as “high risk” using these approaches are referred for fasting blood glucose tests to confirm the diagnosis. Although the Indian government plans to expand this screening program, no data have been collected to track its performance. Here, the researchers develop a microsimulation model (a computer model that operates at the level of individuals) to investigate the implications of using alternative screening instruments to identify people with undetected diabetes across diverse populations in India.
What Did the Researchers Do and Find?
The researchers constructed a synthetic nationally representative population of Indians aged 25–65 years using data from 58 sub-national studies. They then used their microsimulation model to estimate the diagnostic and health system implications of using three survey-based screening instruments and glucometer-based screening to identify individuals in this population with diabetes. Depending on which approach was used for screening, between 158 million and 306 million of the 567 million Indians eligible for screening would be classified as high risk for diabetes and would be referred for confirmatory testing, according to the model. However, between 126 million and 273 million of these high-risk individuals would be false positives; only between 26 million and 37 million of these individuals would meet the international diagnostic criteria for diabetes (true positives). The researchers estimate that the cost per case found would vary from US$5.28 (when using random glucose screening) to US$17.06 (when using a survey-based screening instrument). Finally, they estimate that the total cost for screening the eligible population would be between US$169 and US$567 million.
What Do These Findings Mean?
Established criteria for implementing screening programs specify that such programs should use reliable instruments that detect a large proportion of true cases (high sensitivity) and that have a low rate of false positives (high specificity). Screening programs should also offer significant therapeutic benefits to individuals diagnosed through screening. The findings of this study suggest that large-scale community-based screening for diabetes in India using the currently available screening instruments is unlikely to meet these criteria. Indeed, because the data used to construct the synthetic population came from published studies that did not capture the situation in the poorest, most rural areas of India, where the proportion of the population with diabetes is thought to be lowest, these findings may overestimate the efficacy and health benefits of screening. The researchers suggest, therefore, that an approach that focuses on symptom-based screening and on improvements in the treatment of already diagnosed individuals might be a more sensible path for India to take to deal with its burgeoning diabetes epidemic than community-based mass screening.
Additional Information.
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001827. The US National Diabetes Information Clearinghouse provides information about diabetes for patients, healthcare professionals, and the general public (in English and Spanish)The UK National Health Service Choices website provides information for patients and caregivers about type 2 diabetes and about living with diabetes; it also provides people’s stories about diabetesThe charity Diabetes UK provides detailed information for patients and caregivers in several languagesThe UK-based non-profit organization HealthTalkOnline has interviews with people about their experiences of diabetesMedlinePlus provides links to further resources and advice about diabetes (in English and Spanish)A statement from the UK National Screening Committee on diabetes screening in adults is available
doi:10.1371/journal.pmed.1001827
PMCID: PMC4437977  PMID: 25992895
18.  Testing Adolescents for Sexually Transmitted Infections in Urban Primary Care Practices: Results from a Baseline Study 
Objective
Sexually active urban adolescents experience a high burden of sexually transmitted infections (STI). Adolescents often access medical care through general primary care providers; their time alone with a provider increases the likelihood that youth will disclose risky behavior, which may result in STI testing. Our goals were to assess the association (if any) between the provision of time alone and STI testing, and describe the rates of STI testing among sexually active adolescents in urban primary care.
Methods
Youth (aged 12–19 years) presenting for care at 4 urban health centers were invited to complete post-visit surveys of their experience. Sexually transmitted infection screening rates were obtained from the clinical information systems (CIS); CIS data were linked to survey responses.
Results
We received 101 surveys. Surveyed youth experienced time alone in 69% of all visits. Time alone varied by age (older teens experienced more time alone), and it occurred more frequently in preventive visits (71%) versus nonpreventive visits (33%). It did not vary by gender. Forty-two of the 46 sexually active youth experienced time alone. Screening rates for sexually active females, either at the index visit or within 6 months prior to the index visit, were 17.9% for human immunodeficiency virus and 32.1% for gonorrhea/Chlamydia. No sexually active surveyed males were tested. Overall screening rates varied widely across practices (human immunodeficiency virus 0%–29%; gonorrhea/Chlamydia 7%–29%). There was no difference in screening rates among youth with and without time alone.
Conclusion
STI testing for adolescents is being conducted in this primary care urban population, especially for sexually active females. However, clinicians in this setting are not screening females consistently enough and rarely screen males. We were unable to test our hypothesis that provision of time alone was associated with a higher rate of STI testing. Site differences suggest substantial variation in clinician practices that should be addressed in quality improvement interventions.
doi:10.1177/2150131911401030
PMCID: PMC3986265  PMID: 23804803
adolescents; Chlamydia; gonorrhea; HIV; primary care; sexually transmitted diseases; sexually transmitted infection testing; survey study; time alone; urban primary care
19.  Consequences of Gestational Diabetes in an Urban Hospital in Viet Nam: A Prospective Cohort Study 
PLoS Medicine  2012;9(7):e1001272.
Jane Hirst and colleagues determined the prevalence and outcome of gestational diabetes mellitus in urban Vietnam and found that choice of criteria greatly affected prevalence, and has implications for the ability of the health system to cope with the number of cases.
Background
Gestational diabetes mellitus (GDM) is increasing and is a risk for type 2 diabetes. Evidence supporting screening comes mostly from high-income countries. We aimed to determine prevalence and outcomes in urban Viet Nam. We compared the proposed International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criterion, requiring one positive value on the 75-g glucose tolerance test, to the 2010 American Diabetes Association (ADA) criterion, requiring two positive values.
Methods and Findings
We conducted a prospective cohort study in Ho Chi Minh City, Viet Nam. Study participants were 2,772 women undergoing routine prenatal care who underwent a 75-g glucose tolerance test and interview around 28 (range 24–32) wk. GDM diagnosed by the ADA criterion was treated by local protocol. Women with GDM by the IADPSG criterion but not the ADA criterion were termed “borderline” and received standard care. 2,702 women (97.5% of cohort) were followed until discharge after delivery. GDM was diagnosed in 164 participants (6.1%) by the ADA criterion, 550 (20.3%) by the IADPSG criterion. Mean body mass index was 20.45 kg/m2 in women with out GDM, 21.10 in women with borderline GDM, and 21.81 in women with GDM, p<0.001. Women with GDM and borderline GDM were more likely to deliver preterm, with adjusted odds ratios (aORs) of 1.49 (95% CI 1.16–1.91) and 1.52 (1.03–2.24), respectively. They were more likely to have clinical neonatal hypoglycaemia, aORs of 4.94 (3.41–7.14) and 3.34 (1.41–7.89), respectively. For large for gestational age, the aORs were 1.16 (0.93–1.45) and 1.31 (0.96–1.79), respectively. There was no significant difference in large for gestational age, death, severe birth trauma, or maternal morbidity between the groups. Women with GDM underwent more labour inductions, aOR 1.51 (1.08–2.11).
Conclusions
Choice of criterion greatly affects GDM prevalence in Viet Nam. Women with GDM by the IADPSG criterion were at risk of preterm delivery and neonatal hypoglycaemia, although this criterion resulted in 20% of pregnant women being positive for GDM. The ability to cope with such a large number of cases and prevent associated adverse outcomes needs to be demonstrated before recommending widespread screening.
Please see later in the article for the Editors' Summary.
Editors' Summary
Background
Gestational diabetes mellitus (GDM) is diabetes that is first diagnosed during pregnancy. Like other types of diabetes, it is characterized by high levels of sugar (glucose) in the blood. Blood-sugar levels are usually controlled by insulin, which is made by the pancreas. Hormonal changes during pregnancy and the baby's growth demands increase a pregnant woman's insulin needs, and if her pancreas cannot make enough insulin, GDM develops, usually in mid-pregnancy. Risk factors for GDM include a high body mass index (a measure of body fat), excessive weight gain or lack of physical activity during pregnancy, and glucose intolerance (an indicator of diabetes that is measured using the “oral glucose tolerance test”). GDM increases the risk of premature delivery, induced delivery, and having a large-for-gestational-age baby (gestation is the time during which the baby develops within the mother). It also increases the baby's risk of having low blood sugar (neonatal hypoglycemia). GDM, which can often be controlled by exercise and diet, usually disappears after pregnancy but increases the risk of diabetes developing later in both mother and baby.
Why Was This Study Done?
The prevalence (occurrence) of diabetes is increasing rapidly, particularly in low/middleincome countries as they become more affluent. Because GDM increases the subsequent risk of diabetes, some experts believe that screening for GDM should be included in prenatal care as part of diabetes preventative strategies. However, most of the evidence supporting GDM screening comes from high-income countries, so in this prospective cohort study (a study that analyses associations between the baseline characteristics of a group of patients and outcomes), the researchers investigate the prevalence of GDM (diagnosed using the oral glucose tolerance test) and the consequences of GDM among women attending an urban hospital in Viet Nam, a low/middle-income country. An oral glucose tolerance test measures a patient's blood-sugar level after an overnight fast, and one and two hours after consuming a sugary drink. The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) and the American Diabetes Association (ADA) guidelines state, respectively, that one and two of these blood-sugar measurements must be abnormally high for a diagnosis of GDM. In this study, the researchers use both guidelines to diagnose GDM.
What Did the Researchers Do and Find?
Nearly 3,000 women who attended the hospital for routine prenatal care had a glucose tolerance test at around 28 weeks' gestation and were followed until discharge after delivery. Women who had GDM diagnosed by the ADA criterion were referred for dietary advice and glucose monitoring. Those diagnosed by the IADPSG criterion only were described as having “borderline” GDM and received standard prenatal care. GDM was diagnosed in 6.1% and 20.3% of the women using the ADA and IADPSG criteria, respectively. After allowing for other factors that might have affected outcomes, compared to women without GDM, women with GDM or borderline GDM were more likely to deliver prematurely, and their babies were more likely to have neonatal hypoglycemia. Also, women with GDM (but not borderline GDM) were more likely to have their labor induced than women without GDM.
What Do These Findings Mean?
These findings show that the criterion used to diagnose GDM markedly affected the prevalence of GDM among pregnant women attending this Vietnamese hospital—the use of the IADPSG criterion more than tripled the prevalence of GDM and meant that a fifth of the study participants were diagnosed as having GDM. Importantly, the findings also show that GDM diagnosed using the IADPSG criterion was associated with an increased risk of preterm delivery and neonatal hypoglycemia. Although these findings may not be generalizable to other settings within Viet Nam or to other countries, they highlight the need to demonstrate that sufficient resources are available to cope with an increased GDM burden before recommending widespread screening using the IADPSG criterion. Moreover, because the long-term significance of GDM diagnosed using the IADPSG criterion is not known, all the potential benefits and harms and the costs of screening and treating GDM in low-income settings need to be further investigated before any recommendation for “universal” GDM screening is made.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10. 1371/journal.pmed.1001272.
The US National Institute of Diabetes and Digestive and Kidney Diseases provides information for patients on diabetes and on gestational diabetes (in English and Spanish)
The UK National Health Service Choices website also provides information for patients about diabetes and about gestational diabetes, including links to other useful resources
The American Diabetes Association also provides detailed information for patients and professionals about all aspects of diabetes, including gestational diabetes (in English and Spanish)
The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) 2010 recommendations on the diagnosis and classification of gestational diabetes are available
The charity Diabetes UK provides detailed information for patients and carers, including information on gestational diabetes; its blog includes a personal story about gestational diabetes, and its website includes a selection of other stories from people with diabetes; the charity Healthtalkonline also has an interview describing a personal experience of gestational diabetes
MedlinePlus provides links to additional resources on diabetes and on gestational diabetes (in English and Spanish)
doi:10.1371/journal.pmed.1001272
PMCID: PMC3404117  PMID: 22911157
20.  Alcohol misuse 
BMJ Clinical Evidence  2009;2009:1017.
Introduction
Alcohol use is a leading cause of mortality and morbidity internationally, and is ranked by the World Health Organization (WHO) as one of the top five risk factors for disease burden. Without treatment, approximately 16% of hazardous or harmful alcohol users will progress to more dependent patterns of alcohol consumption. This review covers interventions in hazardous or harmful, but not dependent, alcohol users.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions in hazardous or harmful drinkers in the primary-care setting? What are the effects of interventions in hazardous or harmful drinkers in the emergency-department setting? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 18 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review, we present information relating to the effectiveness and safety of the following interventions in primary care and in emergency departments: brief intervention (single- or multiple-session); universal screening plus brief interventions; and targeted screening plus brief interventions.
Key Points
Alcohol use is a leading cause of mortality and morbidity internationally, and is ranked by the WHO as one of the top five risk factors for disease burden. Without treatment, approximately 16% of hazardous or harmful alcohol users will progress to more dependent patterns of alcohol consumption.
This review covers interventions in hazardous or harmful (but not dependent) alcohol users. Hazardous alcohol consumption is defined as a pattern of alcohol consumption that increases the individual's risk of alcohol-related harm, but is not currently causing alcohol-related harm.Harmful alcohol consumption is a pattern of consumption likely to have already led to alcohol-related harm.
Single- or multiple-session brief intervention reduces alcohol consumption over 1 year in hazardous drinkers treated in the primary-care setting, but we don't know how it affects mortality.
Brief intervention (single- or multiple-session) is also effective at reducing alcohol consumption in people treated in the emergency department, although the evidence is not as strong.
Adding universal screening to brief intervention enhances its benefits when given in primary care. We don't know how effectiveuniversal screening in emergency departments is, as we found no data.We don't know whether targeted screening is effective, as we found no data assessing its use in primary or emergency care.
PMCID: PMC2907792  PMID: 21718573
21.  Rates of Latent Tuberculosis in Health Care Staff in Russia 
PLoS Medicine  2007;4(2):e55.
Background
Russia is one of 22 high burden tuberculosis (TB) countries. Identifying individuals, particularly health care workers (HCWs) with latent tuberculosis infection (LTBI), and determining the rate of infection, can assist TB control through chemoprophylaxis and improving institutional cross-infection strategies. The objective of the study was to estimate the prevalence and determine the relative risks and risk factors for infection, within a vertically organised TB service in a country with universal bacille Calmette-Guérin (BCG) vaccination.
Methods and Findings
We conducted a cross-sectional study to assess the prevalence of and risk factors for LTBI among unexposed students, minimally exposed medical students, primary care health providers, and TB hospital health providers in Samara, Russian Federation. We used a novel in vitro assay (for gamma-interferon [IFN-γ]) release to establish LTBI and a questionnaire to address risk factors. LTBI was seen in 40.8% (107/262) of staff and was significantly higher in doctors and nurses (39.1% [90/230]) than in students (8.7% [32/368]) (relative risk [RR] 4.5; 95% confidence interval [CI] 3.1–6.5) and in TB service versus primary health doctors and nurses: respectively 46.9% (45/96) versus 29.3% (34/116) (RR 1.6; 95% CI 1.1–2.3). There was a gradient of LTBI, proportional to exposure, in medical students, primary health care providers, and TB doctors: respectively, 10.1% (24/238), 25.5% (14/55), and 55% (22/40). LTBI was also high in TB laboratory workers: 11/18 (61.1%).
Conclusions
IFN-γ assays have a useful role in screening HCWs with a high risk of LTBI and who are BCG vaccinated. TB HCWs were at significantly higher risk of having LTBI. Larger cohort studies are needed to evaluate the individual risks of active TB development in positive individuals and the effectiveness of preventive therapy based on IFN-γ test results.
Gamma-interferon assays were used in a cross-sectional study of Russian health care workers and found high rates of latent tuberculosis infection.
Editors' Summary
Background.
Tuberculosis (TB) is a very common and life-threatening infection caused by a bacterium, Mycobacterium tuberculosis, which is carried by about a third of the world's population. Many people who are infected do not develop the symptoms of disease; this is called “latent infection.” However, it is important to detect latent infection among people in high-risk communities, in order to prevent infected people from developing active disease, and therefore also reduce the spread of TB within the community. 22 countries account for 80% of the world's active TB, and Russia is one of these. Health care workers are particularly at risk for developing active TB disease in Russia, but the extent of latent infection is not known. In order to design appropriate measures for controlling TB in Russia, it is important to know how common latent infection is among health care workers, as well as other members of the community.
Why Was This Study Done?
The researchers here had been studying the spread of tuberculosis in Samara City in southeastern Russia, where the rate of TB disease among health care workers was very high; in 2004 the number of TB cases among health care workers on TB wards was over ten times that in the general population. There was also no information available on the rates of latent TB infection among health care workers in Samara City. The researchers therefore wanted to work out what proportion of health care workers in Samara City had latent TB infection, and particularly to compare groups whom they thought would be at different levels of risk (students, clinicians outside of TB wards, clinicians on TB wards, etc.). Finally, the researchers also wanted to use a new test for detecting latent TB infection. The traditional test for detecting TB infection (tuberculin skin test) is not very reliable among people who have received the Bacillus Calmette-Guérin (BCG) vaccination against TB earlier in life, as is the case in Russia. In this study a new test was therefore used, based on measuring the immune response to two proteins produced by M. tuberculosis, which are not present in the BCG vaccine strain.
What Did the Researchers Do and Find?
In this study the researchers tested health care workers from all the TB clinics in Samara City, as well as other clinical staff and students, for latent tuberculosis. In total, 630 people had blood samples taken for testing. A questionnaire was also used to collect information on possible risk factors for TB. As expected, the rate of latent TB infection was highest among clinical staff working in the TB clinics, 47% of whom were infected with M. tuberculosis. This compared to a 10% infection rate among medical students and 29% infection rate among primary care health workers. The differences in infection rate between medical students, primary care health workers, and TB clinic staff were statistically significant and reflected progressively increasing exposure to TB. Among primary care health workers, past exposure to TB was a risk factor for having latent TB infection.
What Do These Findings Mean?
This study showed that there was a high rate of latent TB infection among health care workers in Samara City and that infection is increasingly likely among people with either past or present exposure to TB. The results suggest that further research should be carried out to test whether mass screening for latent infection, followed by treatment, will reduce the rate of active TB disease among health care workers and also prevent further spread of TB. There are concerns that widespread treatment of latent infection may not be completely effective due to the relatively high prevalence of drug-resistant TB strains and any new initiatives would therefore need to be carefully evaluated.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040055.
The Stop TB Partnership has been set up to eliminate TB as a public health problem; its site provides data and resources about TB in each of the 22 most-affected countries, including Russia
Tuberculosis minisite from the World Health Organization, providing data on tuberculosis worldwide, details of the Stop TB strategy, as well as fact sheets and current guidelines
The US Centers for Disease Control has a tuberculosis minisite, including a fact sheet on latent TB
Information from the US Centers for Disease Control about the QuantiFERON-TB Gold test, used to test for latent TB infection in this study
doi:10.1371/journal.pmed.0040055
PMCID: PMC1796908  PMID: 17298167
22.  Primary care patients reporting concerns about their gambling frequently have other co-occurring lifestyle and mental health issues 
BMC Family Practice  2006;7:25.
Background
Problem gambling often goes undetected by family physicians but may be associated with stress-related medical problems as well as mental disorders and substance abuse. Family physicians are often first in line to identify these problems and to provide a proper referral. The aim of this study was to compare a group of primary care patients who identified concerns with their gambling behavior with the total population of screened patients in relation to co-morbidity of other lifestyle risk factors or mental health issues.
Methods
This is a cross sectional study comparing patients identified as worrying about their gambling behavior with the total screened patient population for co morbidity. The setting was 51 urban and rural New Zealand practices. Participants were consecutive adult patients per practice (N = 2,536) who completed a brief multi-item tool screening primary care patients for lifestyle risk factors and mental health problems (smoking, alcohol and drug misuse, problem gambling, depression, anxiety, abuse, anger). Data analysis used descriptive statistics and non-parametric binomial tests with adjusting for clustering by practitioner using STATA survey analysis.
Results
Approximately 3/100 (3%) answered yes to the gambling question. Those worried about gambling more likely to be male OR 1.85 (95% CI 1.1 to 3.1). Increasing age reduced likelihood of gambling concerns – logistic regression for complex survey data OR = 0.99 (CI 95% 0.97 to 0.99) p = 0.04 for each year older. Patients concerned about gambling were significantly more likely (all p < 0.0001) to have concerns about their smoking, use of recreational drugs, and alcohol. Similarly there were more likely to indicate problems with depression, anxiety and anger control. No significant relationship with gambling worries was found for abuse, physical inactivity or weight concerns. Patients expressing concerns about gambling were significantly more likely to want help with smoking, other drug use, depression and anxiety.
Conclusion
Our questionnaire identifies patients who express a need for help with gambling and other lifestyle and mental health issues. Screening for gambling in primary care has the potential to identify individuals with multiple co-occurring disorders.
doi:10.1186/1471-2296-7-25
PMCID: PMC1468412  PMID: 16606465
23.  Morbidity profile and out of pocket health care expenditure among under five children of an urban area of Puducherry 
Background:
Information on out of pocket (OOP) health care expenditure is essential for health planning and devising strategies for Universal Health Coverage (UHC).
Aims and objectives:
To describe morbidity profile, treatment preferences and OOP expenditure toward health care of under five children in an urban primary health center of Puducherry.
Materials and Methods:
A cross-sectional study was conducted in four Anganwadi centers selected randomly from a total of 13 centers in the urban service area of JIPMER, Puducherry. All mothers of under five children from selected centers were interviewed regarding sociodemographic details, treatment preferences, and expenditure incurred on illness of under five children by the family for a period of 15 days and 3 months (exclusive of past 15 days) preceding the day of interview.
Results:
Among the 164 children studied, 23.8% and 30% reported illnesses in the past 15 days and 3 months, respectively. Most frequent illness reported was respiratory infections. Private facilities (60%) were the preferred sources for seeking health care. Median OOP expenditure in last 15 days was Rs. 375 and Rs. 450 for the past 3 months, amounting to 8% and 6.8% of the total family income, respectively. The majority of the health care expenditure was toward drugs (71%). No money was spent toward healthcare in government facilities.
Conclusion:
Almost all OOP health care expenditure was incurred when the illnesses were managed by private providers. Hence, strategies can be planned to include private providers under UHC.
doi:10.4103/0976-9668.166122
PMCID: PMC4630747  PMID: 26604603
Acute illness; out of pocket expenditure; preferred provider; under five children
24.  Multi-Level Analysis of the Determinants of Receipt of Clinical Preventive Services Among Reproductive-Age Women 
Women's Health Issues  2012;22(3):e243-e251.
Background
We investigate the impact of individual- and county-level contextual variables on women’s receipt of a comprehensive panel of preventive services in a region that includes both urban and rural communities.
Methods
Outcome variables were: a screening and vaccination index (a count of Papanicolaou test, blood pressure check, lipid panel, sexually transmitted infections or HIV test, and influenza vaccination received in the past 2 years) and a preventive counseling index (a count of topics discussed in the past 2 years: smoking and tobacco, alcohol or drugs, violence and safety, pregnancy planning or contraception, diet/nutrition, and sexually transmitted infections). Contextual covariates from the Area Resource File (2004-2005) were appended to prospective survey data from the Central Pennsylvania Women’s Health Study. Individual-level variables included predisposing, enabling, and need-based measures. Contextual variables included community characteristics and healthcare resources, including a measure of primary care physician density specifically designed for this study of women’s preventive care. Multi-level analyses were performed.
Results
We found low overall use of preventive services. In multi-level models, individual-level factors predicted receipt of both screening and vaccinations and counseling services; significant predictors differed for each index. One contextual variable (primary care physician density) predicted receipt of screenings and vaccinations.
Conclusions
Women’s receipt of preventive services was determined primarily by individual-level variables. Different variables predicted receipt of screening and vaccination versus counseling services. A contextual measure, primary care physician density, predicted receipt of preventive screenings and vaccinations. Individual variability in women’s receipt of counseling services is largely explained by psychosocial factors and seeing an obstetrician-gynecologist.
doi:10.1016/j.whi.2011.11.005
PMCID: PMC3345071  PMID: 22269668
Women; adult; preventive health services; cohort studies; U.S.
25.  Acceptability of Physician Directed Academic Detailing to Increase Colorectal Cancer Screening: an Application of the RESPECT Approach 
Health Promotion Perspectives  2015;5(3):169-175.
Background: In developing effective interventions to increase colorectal cancer (CRC) screening in at risk populations, a necessary first requirement is feasibility. This paper describes how the RESPECT approach to health education guided the conceptualization and implementation of physician-directed academic detailing (AD) to increase practice-wide CRC screening uptake.
Methods: Physician-directed AD was one intervention component in a large educational randomized controlled trial to increase CRC screening uptake. Study participants, primarily urban minority, were aged 50 or older, insured for CRC screening with no out-of-pocket expense and out of compliance with current screening recommendations. The trial was conducted in the New York City metropolitan area. Participants identified their primary care physician; 564 individuals were recruited, representing 459 physician practices. Two-thirds of the physician practices were randomized to receive AD. The RESPECT approach, modified for AD, comprises: 1) Rapport, 2) Educate, but don’t overwhelm, 3) Start with physicians where they are, 4) Philosophical orientation based on a humanistic approach to education, 5) Engagement of the physician and his/her office staff, 6) Care and show empathy, and 7) Trust. Feasibility was assessed as rate of AD delivery.
Results: The AD was delivered to 283 (92.5%) of the 306 practices assigned to receive it; 222/283 (78.4%) delivered to the doctor.
Conclusion: The AD was feasible and acceptable to implement across a range of clinical settings. The RESPECT approach offers a framework for tailoring educational efforts, allowing flexibility, as opposed to strict adherence to a highly structured script or a universal approach.
doi:10.15171/hpp.2015.020
PMCID: PMC4667256  PMID: 26634194
Colorectal cancer; Screening; Colonoscopy; Academic detailing

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