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1.  Can community health officer-midwives effectively integrate skilled birth attendance in the community-based health planning and services program in rural Ghana? 
Reproductive Health  2014;11:90.
The burden of maternal mortality in sub-Saharan Africa is very high. In Ghana maternal mortality ratio was 380 deaths per 100,000 live births in 2013. Skilled birth attendance has been shown to reduce maternal mortality and morbidity, yet in 2010 only 68 percent of mothers in Ghana gave birth with the assistance of skilled birth attendants. In 2005, the Ghana Health Service piloted a strategy that involved using the integrated Community-based Health Planning and Services (CHPS) program and training Community Health Officers (CHOs) as midwives to address the gap in skilled attendance in rural Upper East Region (UER). The study assesses the feasibility of and extent to which the skilled delivery program has been implemented as an integrated component of the existing CHPS, and documents the benefits and challenges of the integrated program.
We employed an intrinsic case study design with a qualitative methodology. We conducted 41 in-depth interviews with health professionals and community stakeholders. We used a purposive sampling technique to identify and interview our respondents.
The CHO-midwives provide integrated services that include skilled delivery in CHPS zones. The midwives collaborate with District Assemblies, Non-Governmental Organizations (NGOs) and communities to offer skilled delivery services in rural communities. They refer pregnant women with complications to district hospitals and health centers for care, and there has been observed improvement in the referral system. Stakeholders reported community members’ access to skilled attendants at birth, health education, antenatal attendance and postnatal care in rural communities. The CHO-midwives are provided with financial and non-financial incentives to motivate them for optimal work performance. The primary challenges that remain include inadequate numbers of CHO-midwives, insufficient transportation, and infrastructure weaknesses.
Our study demonstrates that CHOs can successfully be trained as midwives and deployed to provide skilled delivery services at the doorsteps of rural households. The integration of the skilled delivery program with the CHPS program appears to be an effective model for improving access to skilled birth attendance in rural communities of the UER of Ghana.
PMCID: PMC4326211  PMID: 25518900
Community-based service delivery; Ghana; Maternal mortality; Skilled birth attendance
2.  Is there any role for community involvement in the community-based health planning and services skilled delivery program in rural Ghana? 
In Ghana, between 1,400 and 3,900 women and girls die annually due to pregnancy related complications and an estimated two-thirds of these deaths occur in late pregnancy through to 48 hours after delivery. The Ghana Health Service piloted a strategy that involved training Community Health Officers (CHOs) as midwives to address the gap in skilled attendance in rural Upper East Region (UER). CHO-midwives collaborated with community members to provide skilled delivery services in rural areas. This paper presents findings from a study designed to assess the extent to which community residents and leaders participated in the skilled delivery program and the specific roles they played in its implementation and effectiveness.
We employed an intrinsic case study design with a qualitative methodology. We conducted 29 in-depth interviews with health professionals and community stakeholders. We used a random sampling technique to select the CHO-midwives in three Community-based Health Planning and Services (CHPS) zones for the interviews and a purposive sampling technique to identify and interview District Directors of Health Services from the three districts, the Regional Coordinator of the CHPS program and community stakeholders.
Community members play a significant role in promoting skilled delivery care in CHPS zones in Ghana. We found that community health volunteers and traditional birth attendants (TBAs) helped to provide health education on skilled delivery care, and they also referred or accompanied their clients for skilled attendants at birth. The political authorities, traditional leaders, and community members provide resources to promote the skilled delivery program. Both volunteers and TBAs are given financial and non-financial incentives for referring their clients for skilled delivery. However, inadequate transportation, infrequent supply of drugs, attitude of nurses remains as challenges, hindering women accessing maternity services in rural areas.
Mutual collaboration and engagement is possible between health professionals and community members for the skilled delivery program. Community leaders, traditional and political leaders, volunteers, and TBAs have all been instrumental to the success of the CHPS program in the UER, each in their unique way. However, there are problems confronting the program and we have provided recommendations to address these challenges.
PMCID: PMC4251607  PMID: 25113017
Community-based service delivery; Ghana; Skilled birth attendance; Community participation; Community health workers
3.  Using the community-based health planning and services program to promote skilled delivery in rural Ghana: socio-demographic factors that influence women utilization of skilled attendants at birth in Northern Ghana 
BMC Public Health  2014;14:344.
The burden of maternal mortality in sub-Saharan Africa is enormous. In Ghana the maternal mortality ratio was 350 per 100,000 live births in 2010. Skilled birth attendance has been shown to reduce maternal deaths and disabilities, yet in 2010 only 68% of mothers in Ghana gave birth with skilled birth attendants. In 2005, the Ghana Health Service piloted an enhancement of its Community-Based Health Planning and Services (CHPS) program, training Community Health Officers (CHOs) as midwives, to address the gap in skilled attendance in rural Upper East Region (UER). The study determined the extent to which CHO-midwives skilled delivery program achieved its desired outcomes in UER among birthing women.
We conducted a cross-sectional household survey with women who had ever given birth in the three years prior to the survey. We employed a two stage sampling techniques: In the first stage we proportionally selected enumeration areas, and the second stage involved random selection of households. In each household, where there is more than one woman with a child within the age limit, we interviewed the woman with the youngest child. We collected data on awareness of the program, use of the services and factors that are associated with skilled attendants at birth.
A total of 407 households/women were interviewed. Eighty three percent of respondents knew that CHO-midwives provided delivery services in CHPS zones. Seventy nine percent of the deliveries were with skilled attendants; and over half of these skilled births (42% of total) were by CHO-midwives. Multivariate analyses showed that women of the Nankana ethnic group and those with uneducated husbands were less likely to access skilled attendants at birth in rural settings.
The implementation of the CHO-midwife program in UER appeared to have contributed to expanded skilled delivery care access and utilization for rural women. However, women of the Nankana ethnic group and uneducated men must be targeted with health education to improve women utilizing skilled delivery services in rural communities of the region.
PMCID: PMC4020603  PMID: 24721385
Community-based service delivery; Ghana; Maternal mortality; Women service utilization; Skilled attendants at birth
4.  An Evidence-Based Alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT) Curriculum for Emergency Department (ED) Providers Improves Skills and Utilization 
Emergency Departments (EDs) offer an opportunity to improve the care of patients with at-risk and dependent drinking by teaching staff to screen, perform brief intervention and refer to treatment (SBIRT). We describe here the implementation at 14 Academic EDs of a structured SBIRT curriculum to determine if this learning experience improves provider beliefs and practices.
ED faculty, residents, nurses, physician extenders, social workers, and Emergency Medical Technicians (EMTs) were surveyed prior to participating in either a two hour interactive workshops with case simulations, or a web-based program ( A pre-post repeated measures design assessed changes in provider beliefs and practices at three and 12 months post-exposure.
Among 402 ED providers, 74% reported < 10 hours of prior professional alcohol-related education and 78% had < 2 hours exposure in the previous year. At 3-month follow-up, scores for self-reported confidence in ability, responsibility to intervene, and actual utilization of SBIRT skills all improved significantly over baseline. Gains decreased somewhat at 12 months, but remained above baseline. Length of time in practice was positively associated with SBIRT utilization, controlling for gender, race and type of profession. Persistent barriers included time limitations and lack of referral resources.
ED providers respond favorably to SBIRT. Changes in utilization were substantial at three months post-exposure to a standardized curriculum, but less apparent after 12 months. Booster sessions, trained assistants and infrastructure supports may be needed to sustain changes over the longer term.
PMCID: PMC3976968  PMID: 18077305
Brief intervention; alcohol screening; substance abuse; alcohol education
5.  Youth alcohol use and dating abuse victimization and perpetration: A test of the relationships at the daily level in a sample of pediatric emergency department patients who use alcohol 
Journal of interpersonal violence  2012;27(15):2959-2979.
This study retrospectively examined the daily-level associations between youth alcohol use and dating abuse (DA) victimization and perpetration for a six month period.
Timeline Followback (TLFB) interview data were collected from 397 urban emergency department patients, ages 17–21 years old. Patients were eligible if they reported past month alcohol use and past year dating. Generalized estimating equation (GEE) analyses estimated the likelihood of DA on a given day as a function of alcohol use or heavy use (≥4 drinks per day for females, ≥5 drinks per day for males), as compared to non-use.
Approximately 52% of male and 61% of female participants reported experiencing DA victimization ≥1 times during the past six months, and 45% of males and 55% of females reported perpetrating DA ≥1 times. For both males and females, DA perpetration was more likely on a drinking day as opposed to a non-drinking day (ORs 1.70 and 1.69, respectively). DA victimization was also more likely on a drinking day as opposed to a non-drinking day for both males and females (ORs 1.23 and 1.34, respectively). DA perpetration and DA victimization were both more likely on heavy drinking days as opposed to non-drinking days (2.04 and 2.03 for males’ and females’ perpetration, respectively; and 1.41 and 1.43 for males’ and females’ victimization, respectively).
This study found that alcohol use was associated with increased risk for same day DA perpetration and victimization, for both male and female youth. We conclude that for youth who use alcohol, alcohol use is a potential risk factor for DA victimization and perpetration.
PMCID: PMC3678358  PMID: 22550149
6.  Qualitative analysis of cocaine and heroin users’ main partner sex-risk behavior: is safety in love safety in health? 
In 2009, 27% of the 48,100 estimated new cases of HIV were attributed to heterosexual contact with an infected or at-risk person. Sexually active adults are less likely to use condoms in relationships with main partners than with non-regular partners, despite general knowledge that condom use reduces HIV transmission.
The purpose of this secondary qualitative analysis was to explore and contextualize perceptions of main partnerships, HIV risk, and attitudes toward condom use within main partner relationships among a subsample of intervention-arm cocaine- and/or heroin-using patients enrolled in a negative trial of brief motivational intervention to reduce the incidence of sexually transmitted disease and unsafe sexual behaviors. The open-ended portion of these interview audiotapes consisted of questions about perceptions of risk and attitudes about condom use with main partners. Enrollees were aged 18-54, English or Spanish speaking, and included in this analysis only if they reported having a main partner. We identified codes and elaborated important themes through a standard inductive three step coding process, using HyperRESEARCH™ software.
Among 48 interviewees, 65% were male, half were non-Hispanic white, over 60% were 20-39 years of age, 58% had intravenous drug use (IDU), and 8% were HIV-positive. Participants defined respect, support, trust, and shared child-rearing responsibility as the most valued components of main partner relationships. Condom use was viewed occasionally as a positive means of showing respect with main partners but more often as a sign of disrespect and a barrier to intimacy and affection. Enrollees appraised their partners’ HIV risk in terms of perceptions of physical health, cleanliness, and sexual and HIV testing history. They based decisions regarding condom use mainly on perceived faithfulness, length of involvement, availability of condoms, and pregnancy desirability.
Risk appraisal was commonly based on appearance and subjective factors, and condom use with main sexual partners was described most often as a demonstration of lack of trust and intimacy.
Trial registration
PMCID: PMC3698184  PMID: 23618318
HIV; Main partner; Heterosexual transmission; Sexual profiling; Heroin; Cocaine; Intravenous drug use (IDU)
9.  Age and sharing of needle injection equipment in a cohort of Massachusetts injection drug users: an observational study 
Hepatitis C infection (HCV) among individuals aged 15–24 years has increased in Massachusetts, likely due to injection drug use. The prevalence of injection equipment sharing (sharing) and its association with age was examined in a cohort of out-of-treatment Massachusetts substance users.
This analysis included baseline data from a behavioral intervention with substance users. Younger and older (<25 versus ≥25 years) injection drug users were compared on demographic characteristics, substance use practices, including factors present during the most recent sharing event (“event-level factors”), and HCV testing history.
Sharing was reported by 41% of the 484 individuals who reported injection drug use in the past 30 days. Prevalence of sharing varied by age (50% <25 years old versus 38% ≥25 years, p = 0.02). In a multivariable logistic regression model younger versus older individuals had twice the odds of sharing (95% CI = 1.26, 3.19). During their most recent sharing event, fewer younger individuals than older had their own drugs available (50% versus 75%, p < 0.001); other injection event-level factors did not vary by age. In the presence of PTSD, history of exchanging sex for money, or not being US born, prevalence of sharing by older users was higher and was similar to that of younger users, such that there was no association between age and sharing.
In this cohort of injection drug users, younger age was associated with higher prevalence of sharing, but only in the absence of certain stressors. Harm reduction efforts might benefit from intervening on mental health and other stressors in addition to substance use. Study findings suggest a particular need to address the dangers of sharing with young individuals initiating injection drug use.
PMCID: PMC3880095  PMID: 24330568
Injection drug use; Injection equipment sharing; Young age; Hepatitis C
11.  Screening and Brief Intervention for Unhealthy Drug Use in Primary Care Settings: Randomized Clinical Trials Are Needed 
Journal of addiction medicine  2010;4(3):123-130.
The efficacy of screening and brief intervention (SBI) for drug use in primary care patients is largely unknown. Because of this lack of evidence, US professional organizations do not recommend it. Yet, a strong theoretical case can be made for drug SBI. Drug use is common and associated with numerous health consequences, patients usually do not seek help for drug abuse and dependence, and SBI has proven efficacy for unhealthy alcohol use. On the other hand, the diversity of drugs of abuse and the high prevalence of abuse and dependence among those who use them raise concerns that drug SBI may have limited or no efficacy. Federal efforts to disseminate SBI for drug use are underway, and reimbursement codes to compensate clinicians for these activities have been developed. However, the discrepancies between science and policy developments underscore the need for evidence-based research regarding the efficacy of SBI for drug use. This article discusses the rationale for drug SBI and existing research on its potential to improve drug-use outcomes and makes the argument that randomized controlled trials to determine its efficacy are urgently needed to bridge the gap between research, policy, and clinical practice.
PMCID: PMC2950314  PMID: 20936079
addiction; drug use; primary care; drug screening; brief intervention
12.  Clinical Case Discussion: Screening and Brief Intervention for Drug Use in Primary Care 
Journal of addiction medicine  2010;4(3):131-136.
PMCID: PMC2989621  PMID: 21113433
primary care; drug use; substance use; screening; brief intervention; motivational interviewing
13.  A Brief Motivational Interview in a Pediatric Emergency Department, Plus 10-Day Telephone Follow-Up, Increases Attempts to Quit Drinking Among Youth and Young Adults Who Screen Positive for Problematic Drinking 
Adolescents in their late teens and early twenties have the highest alcohol consumption in the United States; binge drinking peaks at age 21 years. Underage drinking is associated with many negative consequences, including academic problems and risk of intentional and unintentional injuries. This study tested the effectiveness of pediatric emergency department (PED) screening and brief intervention to reduce alcohol consumption and associated risks.
A three-group randomized assignment trial was structured to test differences between intervention (I) and standard assessed control (AC) groups in alcohol consumption and alcohol-related behaviors from baseline to 12 months, and to compare the AC group with a minimally assessed control group (MAC) to adjust for the effect of assessment reactivity on control group behavior. Patients aged 14–21 years were eligible if they screened positive on the Alcohol Use Disorders Identification Test (AUDIT), or for binge drinking or high-risk behaviors. The MAC group received a resource handout, written advice about alcohol-related risks, and a 12-month follow-up appointment. Patients in the AC group were assessed using standardized instruments in addition to the MAC protocol. The intervention group received a peer-conducted motivational intervention, erral to community resources and treatment if indicated, and a ten-day booster in addition to assessment. Measurements included 30 day self-report of alcohol consumption and alcohol-related behaviors, screens for depression and posttraumatic stress disorder, and self-report of attempts to quit, cut back, or change conditions of use, all repeated at follow-up. Motor vehicle records and medical records were also analyzed for changes from baseline to one year follow-up.
Among 7,807 PED patients screened, 1,202 were eligible; 853 enrolled (I n = 283; AC n = 284; MAC n = 286), with a 12-month follow-up rate of 72%. At 12 months, more than half of enrollees in RAP (Reaching Adolescents for Prevention) attempted to cut back on drinking, and over a third tried to quit. A significantly larger proportion of the I group made efforts to quit drinking and to be careful about situations when drinking compared to AC enrollees, and there was a numerically but not significantly greater likelihood (p = 0.065) among the I group for efforts to cut back on drinking. At three months, the likelihood of the I group making attempts to cut back was almost triple that of ACs. For efforts to quit, it was double, and for trying to be careful about situations when drinking, there was a 72% increase in the odds ratio for the I group. Three-month results for attempts were sustained at 12 months for quit attempts and efforts to be careful. Consumption declined in both groups from baseline to 3 months to 12 months, but there were no significant between-group differences in alcohol-related consequences at 12 months, or in alcohol-related risk behaviors. We found a pattern suggestive of assessment reactivity in only one variable at 12 months: the attempt to cut back (73.3% for the I group vs. 64.9% among the AC group, and 54.8% among the MAC group).
Brief motivational intervention resulted in significant efforts to change behavior (quit drinking and be careful about situations while drinking) but did not alter between-group consumption or consequences.
PMCID: PMC2913305  PMID: 20670329
youth drinking; brief intervention; SBIRT; motivational interviewing; alcohol consequences
14.  Screening and Brief Intervention to Reduce Marijuana Use Among Youth and Young Adults in a Pediatric Emergency Department 
PMCID: PMC2910362  PMID: 20053238
emergency department; marijuana; screening; brief intervention; motivational interviewing; youth
Journal of addictions nursing  2009;20(3):127-131.
A randomized clinical controlled trial of screening, brief intervention and referral to treatment (SBIRT) for drinking and related problems among at-risk and dependent drinkers, using nurse interventionists, was undertaken in an emergency room (ER) in Sosnowiec, Poland, the first level-one trauma center in that country. This study was the first outside of the U.S. to test protocols developed in a 14-site collaborative SBIRT study. Because Poland has both a pattern of heavy drinking and a highly accessible specialized alcohol treatment system, it offered a key setting for cultural translation of SBIRT to the international context of a new and emerging health care system. It also offered the opportunity to test the effectiveness of SBIRT with both at-risk and dependent drinkers, and to test the feasibility of using ER nursing staff to provide the brief intervention, serving as a potential model for ongoing implementation of SBIRT in ER settings. Findings suggest that the U.S.-based SBIRT protocols can be successfully translated to other cultures, and that nurses can be successfully trained to provide brief intervention for problem drinking in the ER setting.
PMCID: PMC2800373  PMID: 20046538
16.  Racial and Ethnic Diversity among a Heroin and Cocaine Using Population: Treatment System Utilization 
Journal of addictive diseases  2005;24(4):43-63.
Knowledge about the meanings and consequences of behaviors associated with drug use among diverse populations is essential for developing effective public health and clinical strategies. In this study we identify racial/ethnic variations in patterns of drug use, Addiction Severity Index (ASI) scores, response to intervention, concordance between self-report of drug use and biochemical confirmation, and treatment system contacts in a sample of 1175 out-of-treatment cocaine and heroin users drawn from a trial of brief motivation in the outpatient clinics of an inner-city academic hospital. Key differences were identified in drug of choice, in all of the ASI domains except medical, in validity of self-report of use, and in rate of treatment contact. Differences related to race and ethnicity should be evaluated to determine needs for a variety of substance abuse treatment modalities, assure timely access to culturally competent care, and develop policies that are tailored to real conditions.
PMCID: PMC1761118  PMID: 16368656
cocaine; heroin; opiates; racial/ethnic disparities

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