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Downe S.,Health in Reach
The Cochrane database of systematic reviews | Year: 2013

Vaginal examinations have become a routine intervention in labour as a means of assessing labour progress. Used at regular intervals, either alone or as a component of the partogram (a pre-printed form providing a pictorial overview of the progress of labour), the aim is to assess if labour is progressing physiologically, and to provide an early warning of slow progress. Abnormally slow progress can be a sign of labour dystocia, which is associated with maternal and fetal morbidity and mortality, particularly in low-income countries where appropriate examinations with routine rectal examinations to assess the progress of labour, we identified no difference in neonatal infections requiring antibiotics (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.01 to 8.07, one study, 307 infants). There were no data on the other primary outcomes of length of labour, maternal infections requiring antibiotics and women's overall views of labour. The study did show that significantly fewer women reported that vaginal examination was very uncomfortable compared with rectal examinations (RR 0.42, 95% CI 0.25 to 0.70, one study, 303 women). We identified no difference in the secondary outcomes of augmentation, caesarean section, spontaneous vaginal birth, operative vaginal birth, perinatal mortality and admission to neonatal intensive care.Comparing two-hourly vaginal examinations with four-hourly vaginal examinations in labour, we found no difference in length of labour (mean difference in minutes (MD) -6.00, 95% CI -88.70 to 76.70, one study, 109 women). There were no data on the other primary outcomes of maternal or neonatal infections requiring antibiotics, and women's overall views of labour. We identified no difference in the secondary outcomes of augmentation, epidural for pain relief, caesarean section, spontaneous vaginal birth and operative vaginal birth. On the basis of women's preferences, vaginal examination seems to be preferred to rectal examination. For all other outcomes, we found no evidence to support or reject the use of routine vaginal examinations in labour to improve outcomes for women and babies. The two studies included in the review were both small, and carried out in high-income countries in the 1990s.  It is surprising that there is such a widespread use of this intervention without good evidence of effectiveness, particularly considering the sensitivity of the procedure for the women receiving it, and the potential for adverse consequences in some settings.The effectiveness of the use and timing of routine vaginal examinations in labour, and other ways of assessing progress in labour, including maternal behavioural cues, should be the focus of new research as a matter of urgency. Women's views of ways of assessing labour progress should be given high priority in any future research in this area.

Hoagwood K.E.,New York University | Jensen P.S.,Health in Reach | Acri M.C.,New York University | Serene Olin S.,New York University | And 2 more authors.
Journal of the American Academy of Child and Adolescent Psychiatry | Year: 2012

Objective: Child mental health treatment and services research yields more immediate public health benefit when they focus on outcomes of relevance to a broader group of stakeholders. We reviewed all experimental studies of child and adolescent treatment and service effectiveness published in the last 15 years (1996-2011) and compared the distribution and types of outcome domains to a prior review that focused on studies from the prior 15 years (1980-1995). Method: Studies were included if they focused on children from birth to 18 years of age with specific or general psychiatric conditions, employed randomized designs, and examined intervention effects with a six-month or longer post-treatment assessment in treatment studies or a 6-month or longer post-baseline assessment for services studies. Two hundred (n=200) studies met criteria. Reported outcome measures were coded into conceptual categories drawn from the 1980-1995 review. Results: There was a five-fold increase in the total number of studies (38 versus 200) across the two 15-year time periods, with the largest increase in the number of studies that focused on consumer-oriented outcomes (from eight to 47 studies, an almost sixfold increase); two new domains, parent symptoms and health-related outcomes, were identified. The majority of studies (more than 95) continued to focus on symptoms and diagnoses as an outcome. Impact ratings were higher among studies examining four or more outcomes versus one to two outcomes in all categories with the exception of Posttraumatic Stress Disorder. Conclusions: Given major shifts in health care policy affecting mental health services, the emergence of health and parent-related outcomes as well as greater attention to consumer perspectives parallels emerging priorities in health care and can enhance the relevance of child outcome studies for implementation in the real world. © 2012 American Academy of Child and Adolescent Psychiatry.

Mitchell S.G.,Friends Research Institute | Gryczynski J.,Friends Research Institute | Schwartz R.P.,Friends Research Institute | O'Grady K.E.,University of Maryland College Park | And 3 more authors.
Drug and Alcohol Dependence | Year: 2013

Background: Buprenorphine is increasingly being used in community-based treatment programs, but little is known about the optimal level of psychosocial counseling in these settings. The aim of this study was to compare the effectiveness of OP and IOP level counseling when provided as part of buprenorphine treatment for opioid-dependent African Americans. Methods: Participants were African American men and women starting buprenorphine treatment at one of two community-based clinics (N= 300). Participants were randomly assigned to OP or IOP. Measures at baseline, 3- and 6-month included the primary outcome of DSM-IV opioid and cocaine dependence criteria, as well as additional outcomes of illicit opioid and cocaine use (urine test and self-report), criminal activity, retention in treatment, Quality of Life, Addiction Severity Index composite scores, and HIV risk behaviors. Results: Participants assigned to OP received, on average, 3.67 (SD= 1.30). h of counseling per active week in treatment. IOP participants received an average of 5.23 (SD= 1.68). h of counseling per active week (less than the anticipated 9. h per week of counseling). Both groups showed substantial improvement over a 6-month period on nearly all measures considered. There were no significant differences between groups in meeting diagnostic criteria for opioid (p= .67) or cocaine dependence (p= .63). There were no significant between group differences on any of the other outcomes. A secondary analysis restricting the sample to participants meeting DSM-IV criteria for baseline cocaine dependence also revealed no significant between-group differences (all ps. >. .05). Conclusions: Buprenorphine patients receiving OP and IOP levels of care both show short-term improvements. © 2012 Elsevier Ireland Ltd.

Golub M.,Health in Reach
Progress in community health partnerships : research, education, and action | Year: 2011

People of color suffer worse health outcomes than their White counterparts due, in part, to limited access to high-quality specialty care. This article describes the events that led to the Bronx Health REACH coalition's decision to file a civil rights complaint with the New York State Office of the Attorney General alleging that three academic medical centers in New York City discriminated on the basis of payer status and race in violation of Title VI of the Civil Rights Act of 1964, the Hill-Burton Act, New York State regulations, and New York City Human Rights Law. Key Points: Although the problem has not yet been resolved, the related community mobilization efforts have raised public awareness about the impact of disparate care, strengthened the coalition's commitment to achieve health equality, and garnered support among many city and state legislators. Community groups and professionals with relevant expertise can tackle complex systemic problems, but they must be prepared for a long and difficult fight.

Abiiro G.A.,University of Heidelberg | Abiiro G.A.,University for Development Studies | Mbera G.B.,Health in Reach | De Allegri M.,University of Heidelberg
BMC Health Services Research | Year: 2014

Background: In sub-Saharan Africa, universal health coverage (UHC) reforms have often adopted a technocratic top-down approach, with little attention being paid to the rural communities' perspective in identifying context specific gaps to inform the design of such reforms. This approach might shape reforms that are not sufficiently responsive to local needs. Our study explored how rural communities experience and define gaps in universal health coverage in Malawi, a country which endorses free access to an Essential Health Package (EHP) as a means towards universal health coverage. Methods. We conducted a qualitative cross-sectional study in six rural communities in Malawi. Data was collected from 12 Focus Group Discussions with community residents and triangulated with 8 key informant interviews with health care providers. All respondents were selected through stratified purposive sampling. The material was tape-recorded, fully transcribed, and coded by three independent researchers. Results: The results showed that the EHP has created a universal sense of entitlements to free health care at the point of use. However, respondents reported uneven distribution of health facilities and poor implementation of public-private service level agreements, which have led to geographical inequities in population coverage and financial protection. Most respondents reported affordability of medical costs at private facilities and transport costs as the main barriers to universal financial protection. From the perspective of rural Malawians, gaps in financial protection are mainly triggered by supply-side access-related barriers in the public health sector such as: shortages of medicines, emergency services, shortage of health personnel and facilities, poor health workers' attitudes, distance and transportation difficulties, and perceived poor quality of health services. Conclusions: Moving towards UHC in Malawi, therefore, implies the introduction of appropriate interventions to fill the financial protection gaps in the private sector and the access-related gaps in the public sector and/or an effective public-private partnership that completely integrates both sectors. Current universal health coverage reforms need to address context specific gaps and be carefully crafted to avoid creating a sense of universal entitlements in principle, which may not be effectively received by beneficiaries due to contextual and operational bottlenecks. © 2014 Abiiro et al.; licensee BioMed Central Ltd.

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