Promoting wellbeing and empowerment via Youth First: Exploring psychosocial outcomes of a school-based resilience intervention in Bihar, India.

Youth worldwide are struggling with increased mental health concerns. As youth in low- and middle-income countries make up more than 20% of the world's population, finding ways to improve their psychosocial wellbeing is crucial. CorStone's Youth First program is a school-based psychosocial resilience program that seeks to improve the mental, physical, social, and educational wellbeing of early adolescents. The program is delivered via trained government schoolteachers who facilitate students' learning and development in small groups using a discussion and activity-based curriculum. In August 2021, a study among 322 adolescents was conducted to investigate and compare program participants' and non- participants' understanding and use of inter- and intra-personal psychosocial skills. Focus group discussions were held with students in eight intervention schools and four comparable schools not receiving the intervention (control). Through the focus group discussions, students provided their opinions, thoughts, and ideas about vignettes describing challenges that youth in their communities frequently face, including early marriage and financial pressures. Analysis integrated qualitative and quantitative approaches, consisting of an iterative thematic analysis process followed by quantizing data and conducting t-tests. Youth who had received Youth First had greater awareness of problems, perspective-taking, problem-solving strategies, helping approaches, awareness of their own strengths, and visions for the future, when compared with the control group. Findings provide insights into potential outcomes for measurement in future evaluations of mental health promotion and prevention programs among youth in low- and middle-income countries.

Large-Scale Evaluation of Quality of Care in 6 Countries of Eastern Europe and Central Asia Using Clinical Performance and Value Vignettes.

BACKGROUND: A significant determinant of population health outcomes is the quality of care provided for noncommunicable diseases, obstetric, and pediatric care. We present results on clinical practice quality in these areas as measured among nearly 4,000 providers working at more than 1,000 facilities in 6 Eastern European and Central Asian countries. METHODS: This study was conducted between March 2011 and April 2013 in Albania, Armenia, Georgia, Kazakhstan, Kirov Province in Russia, and Tajikistan. Using a probability proportional-to-size sampling technique, based on number of hospital beds, we randomly selected within each country 42 hospitals and their associated primary health care clinics. Physicians and midwives within each clinical area of interest were randomly selected from each hospital and clinic and asked how they would care for simulated patients using Clinical Performance and Value (CPV) vignettes. Facility administrators were also asked to complete a facility survey to collect structural measures of quality. CPV vignettes were scored on a scale of 0% to 100% for each provider. We used descriptive statistics and t tests to identify significant differences in CPV scores between hospitals and clinics and rural vs. urban facilities, and ANOVA to identify significant differences in CPV scores across countries. RESULTS: We found that quality of care, as concurrently measured by performance on CPV vignettes, was generally poor and widely variable within and between countries. Providers in Kirov Province, Russia, had the highest overall performance, with an average score of 70.8%, while providers in Albania and Tajikistan had the lowest average score, each at 50.8%. The CPV vignettes with the lowest scores were for multiple noncommunicable disease risk factors and birth asphyxia. A considerable proportion (11%) of providers performed well on the CPV vignettes, regardless of country, facility, or structural resources available to them. CONCLUSIONS: Countries of Eastern Europe and Central Asia are challenged by poor performance as measured by clinical care vignettes, but there is potential for provision of high-quality care by a sizable proportion of providers. Large-scale assessments of quality of care have been hampered by the lack of effective measurement tools that provide generalizable and reliable results across diverse economic, cultural, and social settings. The feasibility of quality measurement using CPV vignettes in these 6 countries and the ability to combine results with individual feedback could significantly enhance strategies to improve quality of care, and ultimately population health.

Impact of a protein-based assay that predicts prostate cancer aggressiveness on urologists' recommendations for active treatment or active surveillance: a randomized clinical utility trial.

BACKGROUND: Of the more than 1.1 million men diagnosed worldwide annually with prostate cancer, the majority have indolent tumors. Distinguishing between aggressive and indolent cancer is an important clinical challenge. The current approaches for assessing tumor aggressiveness are recognized as insufficient. A validated protein-based assay has been shown to predict tumor aggressiveness from prostate biopsy. The main objective of this study was to measure the clinical utility of this new assay in the management of early-stage prostate cancer. METHODS: One hundred twenty nine board-certified urologists were asked to participate in a randomized, two-arm experiment. We collected data over 2 rounds using simulated clinical cases administered via an online platform. The cases were all newly diagnosed Gleason 3 + 3 or 3 + 4 prostate camcer patients. Urologists in the intervention arm received a 15-min webinar on this protein-based assay and given assay test results for their simulated patients in round 2. Each case had a preferred recommendation of either active surveillance or active treatment. The measured outcome was rate of preferred recommendation, defined as urologists who recommended the proper treatment course. Analyses were done using difference-in-difference estimations. RESULTS: Using multinomial logistical regression, urologists who were given the assay results were significantly more likely to choose the preferred recommendation (active surveillance or active treatment) compared to controls (p = 0.004). These urologists were also significantly more likely to involve their patients in the treatment decision compared to controls (p = 0.001). CONCLUSIONS: By providing additional information to inform the physician's treatment plan, a protein-based assay shows demonstrable clinical utility confirmed through a rigorous randomized controlled study design and regression analyses to test for effects.

Indications for Cesarean Delivery in Mexico: Evaluation of Appropriate Use and Justification.

BACKGROUND: Cesarean delivery is one of the most widely used surgical interventions in Latin America and in many cases it is performed with no clear medical indication. Our objective was to analyze the relationship between reported indications for a cesarean and support for that indication in the clinical record in four Mexican hospitals, during the 2006-2007 period. METHODS: The data are from 604 (37.1%) women from a total of 1,625 who were admitted to the hospital in labor, and who gave birth through cesarean. Multivariate logistical regression analysis was used to explore the association between indications for clinically justified or unjustified surgery and other clinical and sociodemographic variables. RESULTS: Supporting clinical information for indications of cesarean delivery were found in only 45 percent of the cases considered. The adjusted statistical analysis showed that the variables associated with an unjustified indication for cesarean were: not having had a prior birth (OR 1.84 [95% CI 1.16-2.89]), having a maximum cervical dilation of 4 centimeters or less at time of cesarean (OR 2.44 [95% CI 1.53-3.87]), and having received care in a private hospital (OR 6.11 [95% CI 1.90-19.57]). DISCUSSION: The indications for cesarean related to labor dynamics were those least supported. Not having had a prior birth poses the greatest risk of having a poorly supported indication for a cesarean delivery. It would be prudent to institute audits, and greater requirements for and surveillance of documentation for cesarean delivery indications.

Clinical Utility of a Comprehensive, Whole Genome CMA Testing Platform in Pediatrics: A Prospective Randomized Controlled Trial of Simulated Patients in Physician Practices.

BACKGROUND: Developmental disorders (DD), including autism spectrum disorder (ASD) and intellectual disability (ID), are a common group of clinical manifestations caused by a variety of genetic abnormalities. Genetic testing, including chromosomal microarray (CMA), plays an important role in diagnosing these conditions, but CMA can be limited by incomplete coverage of genetic abnormalities and lack of guidance for conditions rarely seen by treating physicians. METHODS: We conducted a longitudinal, randomized controlled trial investigating the impact of a higher resolution 2.8 million (MM) probe-CMA test on the quality of care delivered by practicing general pediatricians and specialists. To overcome the twin problems of finding an adequate sample size of multiple rare conditions and under/incorrect diagnoses, we used standardized simulated patients known as CPVs. Physicians, randomized into control and intervention groups, cared for the CPV pediatric patients with DD/ASD/ID. Care responses were scored against evidence-based criteria. In round one, participants could order diagnostic tests including existing CMA tests. In round two, intervention physicians could order the 2.8MM probe-CMA test. Outcome measures included overall quality of care and quality of the diagnosis and treatment plan. RESULTS: Physicians ordering CMA testing had 5.43% (p<0.001) higher overall quality scores than those who did not. Intervention physicians ordering the 2.8MM probe-CMA test had 7.20% (p<0.001) higher overall quality scores. Use of the 2.8MM probe-CMA test led to a 10.9% (p<0.001) improvement in the diagnosis and treatment score. Introduction of the 2.8MM probe-CMA test led to significant improvements in condition-specific interventions including an 8.3% (p = 0.04) improvement in evaluation and therapy for gross motor delays caused by Hunter syndrome, a 27.5% (p = 0.03) increase in early cognitive intervention for FOXG1-related disorder, and an 18.2% (p<0.001) improvement in referrals to child neurology for Dravet syndrome. CONCLUSION: Physician use of the 2.8MM probe-CMA test significantly improves overall quality as well as diagnosis and treatment quality for simulated cases of pediatric DD/ASD/ID patients, and delivers additional clinical utility over existing CMA tests.

Improving Clinical Practice Using a Novel Engagement Approach: Measurement, Benchmarking and Feedback, A Longitudinal Study.

BACKGROUND: Poor clinical outcomes are caused by multiple factors such as disease progression, patient behavior, and structural elements of care. One other important factor that affects outcome is the quality of care delivered by a provider at the bedside. Guidelines and pathways have been developed with the promise of advancing evidence-based practice. Yet, these alone have shown mixed results or fallen short in increasing adherence to quality of care. Thus, effective, novel tools are required for sustainable practice change and raising the quality of care. METHODS: The study focused on benchmarking and measuring variation and improving care quality for common types of breast cancer at four sites across the United States, using a set of 12 Clinical Performance and Value(®) (CPV(®)) vignettes per site. The vignettes simulated online cases that replicate a typical visit by a patient as the tool to engage breast cancer providers and to identify and assess variation in adherence to evidence-based practice guidelines and pathways. RESULTS: Following multiple rounds of CPV measurement, benchmarking and feedback, we found that scores had increased significantly between the baseline round and the final round (P < 0.001) overall and for all domains. By round 4 of the study, the overall score increased by 14% (P < 0.001), and the diagnosis with treatment plan domain had an increase of 12% (P < 0.001) versus baseline. CONCLUSION: We found that serially engaging breast cancer providers with a validated clinical practice engagement and measurement tool, the CPVs, markedly increased quality scores and adherence to clinical guidelines in the simulated patients. CPVs were able to measure differences in clinical skill improvement and detect how fast improvements were made.

A psychosocial resilience curriculum provides the "missing piece" to boost adolescent physical health: A randomized controlled trial of Girls First in India.

RATIONALE AND OBJECTIVES: Despite a recent proliferation of interventions to improve health, education, and livelihoods for girls in low and middle income countries, psychosocial wellbeing has been neglected. This oversight is particularly problematic as attending to psychosocial development may be important not only for psychosocial but also physical wellbeing. This study examines the physical health effects of Girls First, a combined psychosocial (Girls First Resilience Curriculum [RC]) and adolescent physical health (Girls First Health Curriculum [HC]) intervention (RC + HC) versus its individual components (i.e., RC, HC) and a control group. We expected Girls First to improve physical health versus HC and controls. METHODS: Over 3000 girls in 76 government middle schools in rural Bihar, India participated. Interventions were delivered through in-school peer-support groups, facilitated by pairs of local women. Girls were assessed before and after program participation on two primary outcomes (health knowledge and gender equality attitudes) and nine secondary outcomes (clean water behaviors, hand washing, menstrual hygiene, health communication, ability to get to a doctor when needed, substance use, nutrition, safety, vitality and functioning). Analyses included Difference-in-Difference Ordinary Least-Squares Regressions and F-tests for equality among conditions. RESULTS: Girls First significantly improved both primary and eight secondary outcomes (all except nutrition) versus controls. Additionally, Girls First demonstrated significantly greater effects, improving both primary and six secondary outcomes (clean water behaviors, hand washing, health communication, ability to get to a doctor, nutrition, safety) versus HC. CONCLUSIONS: This study is among the first to assess the impact of a combined psychosocial and adolescent health program on physical health. We found that combining these curricula amplified effects achieved by either curriculum alone. These findings suggest that psychosocial wellbeing should receive much broader attention, not only from those interested in improving psychosocial outcomes but also from those interested in improving physical health outcomes.

Building psychosocial assets and wellbeing among adolescent girls: A randomized controlled trial.

We conducted a randomized controlled trial of a 5-month resilience-based program (Girls First Resilience Curriculum or RC) among 2308 rural adolescent girls at 57 government schools in Bihar, India. Local women with at least a 10th grade education served as group facilitators. Girls receiving RC improved more (vs. controls) on emotional resilience, self-efficacy, social-emotional assets, psychological wellbeing, and social wellbeing. Effects were not detected on depression. There was a small, statistically significant negative effect on anxiety (though not likely clinically significant). Results suggest psychosocial assets and wellbeing can be improved for girls in high-poverty, rural schools through a brief school-day program. To our knowledge, this is one of the largest developing country trials of a resilience-based school-day curriculum for adolescents.

Fostering emotional, social, physical and educational wellbeing in rural India: the methods of a multi-arm randomized controlled trial of Girls First.

BACKGROUND: There are 600 million girls in low and middle income countries (LMICs), many of whom are at great risk for poor health and education. There is thus great need for programs that can effectively improve wellbeing for these girls. Although many interventions have been developed to address these issues, most focus on health and education without integrating attention to social and emotional factors. This omission is unfortunate, as nascent evidence indicates that these factors are closely related to health and education. This paper describes the methods of a 4-arm randomized controlled trial among 3,560 adolescent girls in rural Bihar, India that tested whether adding an intervention targeting social-emotional issues (based on a "resilience framework") to an adolescent health intervention would improve emotional, social, physical, and educational wellbeing to a greater extent than its components and a control group. Study arms were: (1) Girls First, a combination of the Girls First Resilience Curriculum (RC) and the Girls First Health Curriculum (HC); (2) Girls First Resilience Curriculum (RC) alone; (3) Girls First Health Curriculum (HC) alone; and (4) a school-as-usual control group (SC). METHODS: Seventy-six schools were randomized (19 per condition) and 74 local women with a tenth grade education were trained and monitored to facilitate the program. Quantitative data were collected from 3,560 girls over 4 assessment points with very low rates of participant attrition. Qualitative assessments were conducted with a subset of 99 girls and 27 facilitators. RESULTS AND CONCLUSIONS: In this article, we discuss guiding principles that facilitated trial implementation, including integrating diverse local and non-local sources of knowledge, focusing on flexibility of planning and implementation, prioritizing systematic measurement selection, and striking a balance between scientific rigor and real-world feasibility. TRIAL REGISTRATION: Clinicaltrials.gov NCT02429661 . Registered 24 April 2015.

Low Rates of Genetic Testing in Children With Developmental Delays, Intellectual Disability, and Autism Spectrum Disorders.

To explore the routine and effective use of genetic testing for patients with intellectual disability and developmental delay (ID/DD), we conducted a prospective, randomized observational study of 231 general pediatricians (40%) and specialists (60%), using simulated patients with 9 rare pediatric genetic illnesses. Participants cared for 3 randomly assigned simulated patients, and care responses were scored against explicit evidence-based criteria. Scores were calculated as a percentage of criteria completed. Care varied widely, with a median overall score of 44.7% and interquartile range of 36.6% to 53.7%. Diagnostic accuracy was low: 27.4% of physicians identified the correct primary diagnosis. Physicians ordered chromosomal microarray analysis in 55.7% of cases. Specific gene sequence testing was used in 1.4% to 30.3% of cases. This study demonstrates that genetic testing is underutilized, even for widely available tests. Further efforts to educate physicians on the clinical utility of genetic testing may improve diagnosis and care in these patients.

Quality of care and health status in Ukraine.

BACKGROUND: We conducted a national level assessment of the quality of clinical care practice in the Ukrainian healthcare system for two important causes of death and chronic disease conditions. We tested two hypotheses: a) quality of care is predicted by physician and facility characteristics and b) health status is predicted by quality of care. METHODS: During 2009-2010 in Ukraine, we collected nationally-representative data from clinical facilities, physicians, Clinical Performance and Value (CPV®) vignettes, patient surveys from the facilities, and from the general population. Each physician completed a written CPV® vignette-a simulated case scenario of a typical patient visit-for each of two clinical cases, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). CPV® vignette scores, calculated as a percentage of all care criteria completed by the physician, were used as the measure of clinical quality of care. Self-reported health measures were collected from exit and household survey respondents. Regression models were developed to test the two study hypotheses. RESULTS: 136 hospitals and 125 polyclinics were surveyed; 1,044 physicians were interviewed and completed CPV® vignettes. On average physicians scored 47.4% on the vignettes. Younger, female physicians provide a higher quality of care-as well as those that have had recent continuing medical education (CME) in chronic disease or health behaviors. Higher quality was associated with better health outcomes. CONCLUSIONS: As low- and middle-income countries around the world are challenged by non-communicable diseases, higher quality of care provided to these populations may result in better outcomes, such as improved health status and life expectancy, and overcome regional shortfalls. Policy efforts that serially evaluate quality may improve chronic disease care.

Does stewardship make a difference in the quality of care? Evidence from clinics and pharmacies in Kenya and Ghana.

OBJECTIVE: To measure level and variation of healthcare quality provided by different types of healthcare facilities in Ghana and Kenya and which factors (including levels of government engagement with small private providers) are associated with improved quality. DESIGN: Provider knowledge was assessed through responses to clinical vignettes. Associations between performance on vignettes and facility characteristics, provider characteristics and self-reported interaction with government were examined using descriptive statistics and multivariate regressions. SETTING: Survey of 300 healthcare facilities each in Ghana and Kenya including hospitals, clinics, nursing homes, pharmacies and chemical shops. Private facilities were oversampled. PARTICIPANTS: Person who generally saw the most patients at each facility. MAIN OUTCOME MEASURE(S): Percent of items answered correctly, measured against clinical practice guidelines and World Health Organization's protocol. RESULTS: Overall, average quality was low. Over 90% of facilities performed less than half of necessary items. Incorrect antibiotic use was frequent. Some evidence of positive association between government stewardship and quality among clinics, with the greatest effect (7% points increase, P = 0.03) for clinics reporting interactions with government across all six stewardship elements. No analogous association was found for pharmacies. No significant effect for any of the stewardship elements individually, nor according to type of engagement. CONCLUSIONS: Government stewardship appears to have some cumulative association with quality for clinics, suggesting that comprehensive engagement with providers may influence quality. However, our research indicates that continued medical education (CME) by itself is not associated with improved care.

Variations and practice in the care of patients with rheumatoid arthritis: quality and cost of care.

INTRODUCTION: Variability in treatment is linked to lower quality of care and higher costs. Rheumatoid arthritis (RA) is a chronic inflammatory disease for which care and management may vary considerably among rheumatologists. The extent of this variability and its cost ramifications have not been widely studied. This prospective study evaluated the quality and variability in care and quantified the potential cost implications. METHODS: We used Clinical Performance and Value® vignettes to measure the quality of RA care among community-based rheumatologists. Three online Clinical Performance and Value® vignettes--representing patients likely seen in practice with mild disease activity (case A), worsening disease activity (case B), and stable disease with a complicating comorbidity (case C)--were administered to each rheumatologist. Responses were scored against evidence-based criteria. Costs were computed using current (2011) Medicare pricing. Data were analyzed using t test and fixed-effects analysis of variance. RESULTS: One hundred eight board-certified rheumatologists (72% were male; mean age, 49.1 years) completed the study. Overall quality scores averaged 61.3%. Those employed by a health system or in a multispecialty practice were more likely to score higher. Highest combined scores for diagnosis and treatment were evident with case A (61.7%) and lowest with case C (46.7%). Up to 79% of rheumatologists ordered at least 1 laboratory test that was considered unnecessary by study protocol criteria, incurring a mean excess cost of $37.85 per physician per case. Up to 26.9% rheumatologists prescribed biologic agents that were not indicated based on American College of Rheumatology treatment guidelines, resulting in additional costs of $2041 per patient per month. CONCLUSION: In this study, we observed a wide range of reported practice variability by rheumatologists in the management of RA. This included unnecessary testing and use of biologic agents that increased the costs of treatment. Opportunities for quality improvement and cost control exist in the management of RA.

Are all skilled birth attendants created equal? A cluster randomised controlled study of non-physician based obstetric care in primary health care clinics in Mexico.

BACKGROUND: the great majority of births in Mexico are attended by physicians. Non-physician health professionals have never been evaluated or compared to the medical model of obstetric care. This study evaluates the relative strengths of adding an obstetric nurse or professional midwife to the physician based team in rural clinics. METHODS: we undertook a cluster-randomised trial in 27 clinics in 2 states with high maternal mortality. Twelve non-physician providers (obstetric nurses (4) and professional midwives (8)) were randomly assigned to clinics; 15 clinics served as control sites. Over an 18-month period in 2009-2010, we evaluated quality of care through chart review and monthly interviews with providers about last three deliveries performed. We analysed practices by creating indices using WHO care guidelines for normal labour and childbirth. Volume of care was assessed using administrative reporting forms. FINDINGS: two thousand two hundred fifty-four pregnancies were followed, and a total of 461 deliveries occurred in study sites. Intervention clinics were more likely to score highly on the index for favourable practices on admission (OR=3.6, 95% CI 2.3-5.8), and during labour, childbirth, and immediately post partum (OR=8.6, 95% CI 2.9-25.6) and less likely to use excessively used or harmful practices during labour, childbirth and immediately post partum (OR=0.2, 95% CI 0.1-0.4). There was a significant increase in volume of care in intervention clinics for antenatal visits (incidence rate ratio (IRR) 1.3, 95% CI 1.2-1.4), deliveries (IRR=2.5, 95% CI 1.7-3.7) and for postpartum visits (IRR=1.4, 95% CI 1.1-1.7). INTERPRETATION: the addition of non-physician skilled birth attendants to rural clinics in Mexico where they independently provided basic obstetric services led to improved care and higher coverage than clinics without. The potential value of including a professional midwife or obstetric nurse in all rural clinics providing obstetric care should be considered. FUNDING: Mexican National Institute for Women, Mexican National Center for Gender Equity and Reproductive Health, MacArthur Foundation, Bill and Melinda Gates Foundation.

Non-physician providers of obstetric care in Mexico: Perspectives of physicians, obstetric nurses and professional midwives.

BACKGROUND: In Mexico 87% of births are attended by physicians. However, the decline in the national maternal mortality rate has been slower than expected. The Mexican Ministry of Health's 2009 strategy to reduce maternal mortality gives a role to two non-physician models that meet criteria for skilled attendants: obstetric nurses and professional midwives. This study compares and contrasts these two provider types with the medical model, analyzing perspectives on their respective training, scope of practice, and also their perception and/or experiences with integration into the public system as skilled birth attendants. METHODOLOGY: This paper synthesizes qualitative research that was obtained as a component of the quantitative and qualitative study that evaluated three models of obstetric care: professional midwives (PM), obstetric nurses (ON) and general physicians (GP). A total of 27 individual interviews using a semi-structured guide were carried out with PMs, ONs, GPs and specialists. Interviews were transcribed following the principles of grounded theory, codes and categories were created as they emerged from the data. We analyzed data in ATLAS.ti. RESULTS: All provider types interviewed expressed confidence in their professional training and acknowledge that both professional midwives and obstetric nurses have the necessary skills and knowledge to care for women during normal pregnancy and childbirth. The three types of providers recognize limits to their practice, namely in the area of managing complications.We found differences in how each type of practitioner perceived the concept and process of birth and their role in this process. The barriers to incorporation as a model to attend birth faced by PMs and ONs are at the individual, hospital and system level. GPs question their ability and training to handle deliveries, in particular those that become complicated, and the professional midwifery model particularly as it relates to a clinical setting, is also questioned. CONCLUSIONS: Hospitals in the Mexican public health sector have a heavy obstetric workload; physicians carry the additional burden of non-obstetric cases. The incorporation of a non- physician model at the primary health center level to attend low-risk, normal deliveries would contribute to the reduction of non-necessary referrals. There is also a role for these providers at the hospital level.

Skilled birth attendants in Mexico: how does care during normal birth by general physicians, obstetric nurses, and professional midwives compare with World Health Organization evidence-based practice guidelines?

INTRODUCTION: We evaluated the quality of basic obstetric care provided by Mexican general physicians, obstetric nurses, and professional midwives compared with World Health Organization (WHO) guidelines for evidence-based practices and national guidelines. METHODS: Vaginal births were observed in 5 hospitals in 5 states from June 2006 until July 2007. We created 5 indices based on WHO guidelines and national standards for care during normal birth. These indices included 1) favorable practices at admission, 2) favorable practices during labor, birth, and immediately postpartum, 3) harmful or excessively used practices, 4) newborn practices, and 5) obstetric outcomes. We assessed each provider type's performance as high or low compared with the WHO standard and performed bivariate and multivariate logistic regression analyses to assess the association between indices, patient characteristics, and provider type, adjusting for standard errors for intragroup correlation. RESULTS: We observed 876 independently managed vaginal births. Adjusted regression analyses compared with the general physicians standard revealed significant results for favorable care by obstetric nurses on admission (odds ratio [OR] 6.25; 95% confidence interval [CI], 2.08-18.84); for care by professional midwives (OR 21.08; 95% CI, 4.24-104.94) and obstetric nurses (OR 7.88; 95% CI, 2.76-22.52) during labor, birth, and postpartum; and for newborn practices by obstetric nurses (OR 4.14; 95% CI, 1.08-15.90). Professional midwives were least likely to perform harmful/excessively used practices during labor, birth, and the postpartum period (OR 0.06; 95% CI, 0.00-0.35). DISCUSSION: Professional midwives and obstetric nurses perform equally or better than general physicians when assessed by use or misuse of evidence-based practices. Professional midwives are an underutilized resource in Mexico. If integrated into the mainstream Mexican health system, they may improve the quality of obstetric care.

Costs of interventions for AIDS orphans and vulnerable children.

OBJECTIVE: To review the published and grey literature for information regarding the costs and cost-effectiveness of interventions aimed at improving the welfare of orphans and vulnerable children owing to HIV/AIDS in low- and middle-income countries. METHOD: We carried out a search of the peer-reviewed literature through PubMed, EconLit, and Web of Science for the period January 2000 to December 2010. We also extensively reviewed the grey literature through generalized web searches and consultations with experts and searches of the web pages of the main organizations active in providing services to orphans and vulnerable children (OVC). The search yielded 216 articles; cross-sectional or longitudinal studies and articles that did not address specific interventions were not considered. The remaining 21 articles were categorized by domain and by type of intervention strategy. RESULTS: All studies reviewed were carried out in sub-Saharan Africa. All outcomes are expressed as cost per child per year (in 2010 USD). Foster care estimates range from $614 to $1921. Educational support for primary school ranged from $30 to $75. Health interventions that would ensure child survival can be delivered for about $55. CONCLUSION: More research is needed to improve planning and delivery of interventions for OVC. The paucity of cost and cost-effectiveness data reflects the limited number of effectiveness studies. Nevertheless, this systematic literature review shows evidence that suggests that in the area of housing, foster care appears to be more cost effective than institutional care (orphanages).

Educación sobre sexualidad y prevención del VIH: un diagnóstico para América Latina y el Caribe / Sex education and HIV prevention: an evaluation in Latin America and the Caribbean

OBJETIVO: Mostrar, a través de un diagnóstico en América Latina y el Caribe, el panorama legislativo y curricular sobre sexualidad y prevención contra el virus de inmunodeficiencia humana (VIH) en el ámbito escolar, contrastándolo con los comportamientos sexuales reportados en encuestas demográficas y de salud. MÉTODOS: En mayo de 2008 se realizó, con el apoyo del Fondo de Población de las Naciones Unidas (UNFPA), una encuesta a informantes clave en 34 países de la Región. El cuestionario autoaplicado solicitó información sustantiva de agentes de las diferentes partes interesadas, como ministerios de educación y de salud, sobre los programas de prevención contra el VIH/ Sida que se están aplicando en las escuelas. RESULTADOS: Respondieron a la encuesta 27 países que representan 95,5 por ciento de la población objetivo (6 a 18 años de edad). La mayoría de los países informó tener al menos un libro de texto o un capítulo específico para enseñar los temas de educación sobre sexualidad y prevención del VIH. En la escuela secundaria se cubren la mayor parte de los temas pertinentes relevantes para la educación sobre sexualidad, pero no todos. Por ejemplo, el problema de la discriminación por orientación o preferencia sexual no se incluye en los programas escolares. CONCLUSIONES: El material educativo sobre sexualidad debe ser revisado y actualizado periódicamente de modo que refleje los avances en los temas y en la forma de tratar los contenidos. En cada país el currículo debe abordar el tema del respeto a la diversidad sobre orientación, preferencia e identidad sexuales, y en particular el manejo apropiado de la educación para prevenir infecciones de transmisión sexual (ITS) en hombres que tienen sexo con hombres. Los esfuerzos de evaluación de la efectividad de los programas deben contemplar desenlaces tales como marcadores biológicos (incidencia y prevalencia de ITS y embarazo) y no únicamente indicadores de conocimiento y comportamiento...

OBJECTIVE: To present, through an evaluation in Latin America and the Caribbean, the current regulatory and curricular landscape of sexuality and HIV prevention in the school setting, and contrast it with sexual behaviors as reported by demographic and health surveys. METHODS: In May 2008, with the support of the United Nations Population Fund (UNFPA), a survey was conducted involving key contacts in 34 countries of the Region. The self-administered questionnaire sought in-depth information on school-based HIV/AIDS prevention programs from the staff of various stakeholders, including ministries of education and of health. RESULTS: Twenty-seven countries responded to the survey, representing 95.5 percent of the target population (6-18 years of age). Most countries reported having at least one textbook or one specific chapter devoted to teaching sex education and HIV prevention. Many, but not all of the important sex education topics, were covered in secondary school; for example, the issue of discrimination based on sexual orientation/ preference is not included in school curricula. CONCLUSIONS: Sex education materials should be reviewed and updated periodically to reflect progress being made on the issues and the handling of the subject matter. In each country, the curriculum should address the issue of respecting differences in sexual orientation, preference, and identity, and especially, an appropriate approach toward sexually-transmitted infection (STI) prevention education among males who have sex with males. Efforts to assess the programs' effectiveness should consider outcomes, such as biomarkers (STI incidence and prevalence and pregnancy), not just indicators of self-reported sexual knowledge and behavior.

[Sex education and HIV prevention: an evaluation in Latin America and the Caribbean]. / Educación sobre sexualidad y prevención del VIH: un diagnóstico para América Latina y el Caribe.

OBJECTIVE: To present, through an evaluation in Latin America and the Caribbean, the current regulatory and curricular landscape of sexuality and HIV prevention in the school setting, and contrast it with sexual behaviors as reported by demographic and health surveys. METHODS: In May 2008, with the support of the United Nations Population Fund (UNFPA), a survey was conducted involving key contacts in 34 countries of the Region. The self-administered questionnaire sought in-depth information on school-based HIV/AIDS prevention programs from the staff of various stakeholders, including ministries of education and of health. RESULTS: Twenty-seven countries responded to the survey, representing 95.5% of the target population (6-18 years of age). Most countries reported having at least one textbook or one specific chapter devoted to teaching sex education and HIV prevention. Many, but not all of the important sex education topics, were covered in secondary school; for example, the issue of discrimination based on sexual orientation/ preference is not included in school curricula. CONCLUSIONS: Sex education materials should be reviewed and updated periodically to reflect progress being made on the issues and the handling of the subject matter. In each country, the curriculum should address the issue of respecting differences in sexual orientation, preference, and identity, and especially, an appropriate approach toward sexually-transmitted infection (STI) prevention education among males who have sex with males. Efforts to assess the programs' effectiveness should consider outcomes, such as biomarkers (STI incidence and prevalence and pregnancy), not just indicators of self-reported sexual knowledge and behavior.