Most readers of this journal will have heard of the International Agency for the Prevention of Blindness (IAPB), but they may not be aware of exactly what the organisation does and how it functions. The purpose of this article is to give a brief overview of what IAPB does and how it contributes to the elimination of avoidable blindness in the world.The IAPB was established in 1975 as a coordinating umbrella organisation to lead international efforts in the prevention of blindness.IAPB presently has 97 members, which include: the major international nongovernmental development organisations (NGDOs) involved in eye health, the international professional bodies representing ophthalmologists and optometrists, universities, World Health Organization (WHO) collaborating centres, some national eye care NGDOs, and five major corporate institutions that fund VISION 2020 programmes.IAPB's member organisations collectively deliver more than 1,500 eye health programmes, in coordination with more than 1,000 partners in over 100 countries.IAPB is the key partner that works on the VISION 2020 initiative with WHO, in particular the WHO prevention of blindness and deafness unit (PBD). This close association, added to its knowledge of eye health programmes based upon the experience of its member organisations, means that IAPB is uniquely placed to provide strategic leadership to VISION 2020. Its work adds value and contributes to the achievement of the initiative in the following specific areas: knowledge and expertise, advocacy, promotion of VISION 2020 programmes for the prevention of blindness, and coordination.IAPB provides knowledge and technical expertise to support the development of quality eye health programmes.IAPB works in partnership with the International Centre for Eye Health (ICEH) to deliver annually more than twenty workshops that promote VISION 2020 around the world.Topics include planning at national and district levels, specific disease control approaches, and advocacy.So far, 150 countries have participated in these workshops and 104 have developed a national VISION 2020 plan. In the future, we hope that the IAPB regions and national coordinators for blindness control will provide us with greater input as to workshop topics and target audiences.A number of IAPB specialist programme committees advise and promote best practice based upon the practical experience of our members' eye health programmes throughout the world.Presently, there are committees for human resource development, technology, cataract, low vision, refractive error, and childhood blindness. Discussion groups also exist to share experience on gender, sustainability, partnership, and primary eye care.In the future, our intention is to disseminate the work of these committees more widely, for example by creating a dedicated section on the VISION 2020 websiteIAPB is involved in advocacy at different levels. It aims to achieve policy change, so that eye health can be integrated, and given greater priority, within national health care services.IAPB has worked with the IAPB East Mediterranean regional chairperson and his team and the WHO PBD unit to secure greater recognition of the importance of blindness control work within WHO structures.Our advocacy efforts have already yielded impressive results. The 2006 World Health Assembly resolution 59.25 requested that prevention of blindness and visual impairment be added to WHO's medium-term strategic plan 2008–13, thus giving greater priority to the prevention of blindness on the global health agenda. It built on the earlier achievement of resolution 56.26 in 2003, which urged all member states to set up national plans by 2005.2At the next World Health Assembly, in May 2009, it is expected that a WHO action plan for the control of avoidable blindness will be approved. This will greatly enhance the importance attached to VISION 2020 within the WHO system and will make WHO a stronger ally to promote the initiative at country level.IAPB also draws together the evidence that will help us to argue more effectively for prioritising resources to support VISION 2020 national plans.For example, IAPB produced a document linking the prevention of blindness with the achievement of the United Nations' millennium development goals (MDGs),IAPB promotes World Sight Day, the key date in our annual calendar to promote awareness of VISION 2020. In 2009, the main theme will be gender. In 2010, when WHO releases new figures on the prevalence of global visual impairment, the theme will be ‘State of the world's sight’. Both these themes will provide exciting opportunities for advocacy.IAPB has been successful in negotiating and subsequently coordinating arrangements with a number of donors to support VISION 2020 development programmes. These are then implemented by IAPB member organisations with local partners.Such programmes include: the Standard Chartered Bank's ‘Seeing is Believing’ programme, which is providing more than US $30 million for rural and urban comprehensive eye care programmes; the Eye Fund, which will provide US $18 million to eye hospitals and IAPB members, in the form of low-interest loans, to enhance their VISION 2020 activities; the Carl-Zeiss IAPB training centre programme, which will provide US $1 million for the development of five training centres to enhance the quality of training of ophthalmic personnel; and the Optometry Giving Sight initiative, which raises funds to develop refractive error programmes.The success of VISION 2020 depends on the contributions of many different stakeholders, including WHO, national and local governments, the private sector, the not-for-profit sector, and local communities. It is therefore essential to have in place:a good exchange of informationcoordinationcollaboration.IAPB has a key role in ensuring that these three elements are in place and that all stakeholders work to a common agenda.Our website,Much has been achieved over the first ten years of VISION 2020, but a great deal more is required if we are to realise our ambition to eliminate avoidable blindness by the year 2020.It is progress at the regional and national levels that will actually lead us to the goals of VISION 2020. Our advocacy work needs to reach a larger number of decision makers, particularly in countries and regions where the level of avoidable blindness continues to be high.We need to attract new funding to support our aspirations to expand our regional presence and, to do this, we need to be better at communicating with potential supporters. When resources allow, we intend to ensure that the regional structure of IAPB is strengthened (see below), so that all regions have a full-time regional coordinator, as presently only the West Pacific and Latin America regions are represented.Above all, we must continue to develop the many partnerships that already exist and craft new relationships - by working together, we can achieve so much more.Community Eye Health Journal reports on a selection of themes discussed during the 8th General Assembly of IAPB (25–28 August 2008). The articles from pages 4 to 12 do not generally contain original results from the authors; they are reports inspired by specific sessions, courses, or symposia which took place during the General Assembly. Relevant details are indicated in the blue panel at the beginning of each article.This issue of the th General Assembly, go to: www.v2020.org/publications-IAPBTo view the Book of Abstracts from the 8communications@v2020.orgFor more information about the original presentations, email: Appoint a full-time coordinator in every regionProvide better support to national. prevention of blindness committees and coordinators through training and visits.Make VISION 2020 programme information available through regional websites.Bring key stakeholders together at regional and subregional levels to share best practice and promote coordination amongst the many agencies involved.Encourage collaborative VISION 2020 development programmes and help to broker implementation funding for IAPB members and their partners.Promote a collaborative approach to our advocacy work.


Few large and rigorous evaluations of participatory interventions systematically describe their context and implementation, or attempt to explain the mechanisms behind their impact. This study reports process evaluation data from the Ekjut cluster-randomised controlled trial of a participatory learning and action cycle with women's groups to improve maternal and newborn health outcomes in Jharkhand and Orissa, eastern India (2005-2008). The study demonstrated a 45% reduction in neonatal mortality in the last two years of the intervention, largely driven by improvements in safe practices for home deliveries.A participatory learning and action cycle with 244 women's groups was implemented in 18 intervention clusters covering an estimated population of 114 141. We describe the context, content, and implementation of this intervention, identify potential mechanisms behind its impact, and report challenges experienced in the field. Methods included a review of intervention documents, qualitative structured discussions with group members and non-group members, meeting observations, as well as descriptive statistical analysis of data on meeting attendance, activities, and characteristics of group attendees.Six broad, interrelated factors influenced the intervention's impact: (1) acceptability; (2) a participatory approach to the development of knowledge, skills and 'critical consciousness'; (3) community involvement beyond the groups; (4) a focus on marginalized communities; (5) the active recruitment of newly pregnant women into groups; (6) high population coverage. We hypothesize that these factors were responsible for the increase in safe delivery and care practices that led to the reduction in neonatal mortality demonstrated in the Ekjut trial.Participatory interventions with community groups can influence maternal and child health outcomes if key intervention characteristics are preserved and tailored to local contexts. Scaling-up such interventions requires (1) a detailed understanding of the way in which context affects the acceptability and delivery of the intervention; (2) planned but flexible replication of key content and implementation features; (3) strong support for participatory methods from implementing agencies. Community participation in health is a cornerstone of the World Health Organization's past and current strategies to achieve health for all ,2. AdvocDespite this ambivalent legacy, commitment to community participation in health is enduring. This is especially true in the field of maternal and child health, where programmes have recognized the importance of community involvement to improve both the supply and demand for appropriate health services . In addiWhile randomised controlled trials are considered the most rigorous method to evaluate the impact of complex interventions, attention must be given to the contextual and process factors that affect the efficacy of such interventions in order to determine how results might be replicated in non-trial settings . CommuniData collection for the Ekjut trial process evaluation began in July 2005, at the start of the women's group intervention. Table A process evaluation manager (SR) collated information on the intervention in theory and as implemented in the field, the social context in which it was delivered and its impact on group members and non-members. Data collection tools were developed in Hindi and Oriya. These included attendance forms, facilitator register books and focus group topic guides. The tools were iteratively adapted throughout the intervention period. The process evaluation included both qualitative data such as case studies, direct observation of meetings and focus group discussions, and quantitative data such as women's group meeting attendance records and data from the trial's main monitoring and evaluation questionnaire for information on group membership status. We used data collected both routinely  and at specific time points (e.g. focus group discussions at the end of the intervention process). Table Group discussions and observations were preferred to other data collection methods because the majority of topics addressed were not sensitive and could be safely discussed within women's groups. In addition, these methods minimised disruptions to the intervention and capitalised on routine data collection. Respondents  were purposefully sampled for their insights into specific intervention components or processes and recruited by SR. Purposefully sampled participants included all group facilitators and women's group members who took part in the final focus group discussions, as well as community members and stakeholders who attended community meetings held as part of the intervention cycle. Verbal consent was sought from groups and community members prior to discussions, and community consent was obtained for the trial. NN analysed the quantitative data using SPSS (version 13). SR analysed the qualitative data thematically in local languages and discussed the results with the senior Ekjut team and AP for consolidation and inputs. The list of mechanisms reported in the results section was compiled by SR and AP with input from all authors. All but three of the authors  were part of the implementation team. All names included in quotes and case studies are pseudonyms.adivasi (indigenous) groups inhabit these areas, including Ho, Santhal, Juang, Bhuiyan, Oraon and Munda communities. In both Jharkhand and Orissa, adivasi groups have distinct identities and strive to safeguard their social institutions and ancestral territories. Subsistence farming and foraging for forest produce are the main sources of livelihood, but these are being increasingly supplemented by wage labour, with men migrating to brick kilns or mines.Documenting the context in which an intervention is developed and implemented is key to understanding its impact . The Ekjadivasi communities in the study area were nature worshippers and interacted ritually with supernatural beings believed to reside in the home and natural environment. Health problems and illnesses were thus often attributed to supernatural causes and local diviners or private providers were commonly used to deal with problems in pregnancy and newborn illnesses.In 12 of the 18 Ekjut intervention clusters, villages were remote and located in hilly terrain surrounded by forests. Because of this physical isolation, villagers had limited access to health services. Among this largely tribal population, newborn health outcomes were poor: in the study clusters where 75% of the population belonged to Scheduled Tribes (ST), the neonatal mortality rate during the trial baseline period (2004-2005) was 58 per 1000 live births, and more than 80% of women delivered their newborns at home without skilled attendance. The intervention clusters were slightly disadvantaged compared with control clusters, with less access to primary health centres and fewer community health workers such as Anganwadi workers or Auxiliary Nurse Midwives. Traditional birth attendants carried out around 36% of home deliveries in the study clusters, and another 37% were carried out by relatives of pregnant women. Most The Indian government's flagship National Rural Health Mission (NRHM) programme was implemented in Jharkhand and Orissa during the study period 2005-2008). The NRHM seeks to improve access to quality health care in rural areas of India. In addition to health service strengthening, the NRHM supports a new community-based volunteer cadre, the Accredited Social Health Activist (ASHA) and seeks to strengthen Village Health Committees (VHCs) to address local health issues and monitor health services. The NRHM also promotes institutional deliveries through a voucher scheme (the Janani Suraksha Yojana or JSY) . JSY was005-2008.There are noteworthy similarities between the Makwanpur and Ekjut trial sites: both are rural areas with poor access to health services. In both sites, over 80% of births occurred at home, and a high proportion of these home deliveries were assisted by relatives or traditional birth attendants. Despite these similarities, the context in which the Ekjut programme was delivered and the intervention itself also had distinctive features that may have contributed to the impact. These are discussed below.bandhs), these did not affect the intervention as facilitators were resident within the clusters and were able to continue running the meetings.The intervention evaluated in the Ekjut trial was a participatory learning and action cycle of 20 meetings adapted from two previous experiences, the Warmi Project in Bolivia, and the Makwanpur women's group cycle in Nepal ,16. WhilLike the Makwanpur study, the Ekjut trial showed a substantial impact on neonatal mortality. This was largely mediated by improvements in safe delivery practices  for home deliveries rather than an increase in health service use. The Ekjut cycle retained three key characteristics of the Warmi and Makwanpur interventions: (1) local acceptability; (2) a participatory approach to the development of knowledge, skills and 'critical consciousness'; (3) community involvement beyond the groups. The ways in which these were operationalised in the context of the Ekjut trial are described below.Three main factors enhanced the intervention's acceptability: the recruitment and training of local facilitators, the use of locally appropriate discussion materials in meetings, and flexibility in the timing and content of meetings. Local trained facilitators are the main intervention implementers and are critical to its success . In ordeAs I am from the same community it is easier for me to interact with the group and understand their health situation. Knowing the local language makes communication easier. She is from our community, she is a friend, she helps us in solving our problems and makes us aware of the problems we suffer from by using picture cards and games, we consider her as a part of us and trust her. .Group members believe our words and the contents discussed during the meetings. They implement them and when they get the benefits their trust strengthens. Facilitators felt that the production and iterative adaptation of locally appropriate picture cards, stories, and participatory games increased acceptability and catalysed learning and planning within the groups. During the pilot phase, innovative facilitation methods were tried out and suitable techniques selected so that each women's group meeting had new activities, was participatory, and took less than two hours.The implementation team and group members suggested that the structured, phase-wise content of the meeting cycle and its emphasis on collective problem solving contributed to learning and confidence building. This appears to have been a key determinant of the intervention's efficacy and acceptability. The following quotes from group members illustrate this:We could not do much as individuals but as a group we could find a way to solve each other's problems. Through story telling we could know some harmful practices and realised that because of some of the age-old practices many mothers and newborns might have lost their lives. It was easy to understand the causes and effects of maternal and newborn problems through picture card stories. By discussing the prevention and home care cards we realised that many diseases could be prevented. (Phase 4 FGD)Games and role play helped to know the step by step process of handling emergencies. (Phase 4 FGD)By sharing experiences with members of other groups we can learn from each other about the strategies that have benefited them. (Phase 4 FGD)Review of the implemented strategies in each meeting helped us in performing our responsibilities properly. (Phase 4 FGD)We are proud that to some extent we have helped in changing the behaviour of our group members and others who do not attend the meetings. (Phase 4 FGD)The implementation team (including facilitators) sought to make cause and effect linkages for health problems apparent through stories and problem-solving games. The process of creating stories was participatory and functioned as a training mechanism: while external staff learned about local practices, local facilitators familiarized themselves with preventive strategies for common problems and rehearsed the discussions which they would then carry out in the groups. Figure Janaki lived in a remote village. When she was pregnant, she decided to visit her relatives who lived on the outskirts of a nearby town. Their house was in a relatively crowded area, with open drains and stagnant water. This is the ideal breeding place for mosquitoes. Her relatives advised her to use mosquito nets because they knew that there were many cases of malaria in this town. However, she ignored their advice and did not use a mosquito net, although she burnt a useful medicinal plant (neem) leaves. Soon afterwards she decided to return to her village but after a week she started to have fever with chills, severe headache and vomiting. She didn't seek care. When she noticed that the baby's movements had reduced she thought about seeing the Auxiliary Nurse Midwife, but the next health day was 5 days away, so instead she listened to the advice of her relatives, who advised her to do rituals and sacrifice two chickens and one goat. Soon afterwards she delivered a stillborn child.Several stories focused on causes of maternal deaths, placing specific emphasis on the need for antenatal care and the prevention of delays in care-seeking. Although the Ekjut trial was not powered to detect a reduction in maternal mortality, we observed fewer maternal deaths in the intervention clusters: there were 49 maternal deaths over 3 years in the intervention clusters compared with 60 in control areas. Several stories such as the one included below, which sought to illustrate the causes of maternal deaths and stimulate discussions about prevention, may have played a part in this reduction:dai (TBA) was called and said "pain has just started and this is her first pregnancy so it will take long, so call me when the pain increases". Throughout the night and the next day, Bamai's pain continued, and by the evening, when she had still not progressed, the relatives called the dai. The dai asked them to wait longer because she was attending to another delivery. Her mother-in-law noticed that the baby's fingers were visible through the vagina and that Bamai was exhausted as she had had nothing to eat or drink. Seeing her deteriorating condition, her relatives called in the ojha  to perform some rituals and then sent for the village doctor. The village doctor came and gave her a hot injection, saying that she would deliver soon. But Bamai was tired and crying with pain. She requested her husband to take her to the hospital, so they started making arrangements to go to the nearest private hospital, which was 15 kms away. This took them a few hours: the roads were bad and they had to borrow money by mortgaging their land. Thirty hours after her pain had started Bamai reached the hospital unconscious and the attending nurse noticed that she was in shock and had lost a lot of blood. The nurse said that Bamai would need an operation for which blood was required because the baby was dead, the hand was lying outside, and the uterus had ruptured. There was no blood bank so the relatives started making arrangements for blood, but in the meantime Bamai was gasping and died.Bamai got married at 16 and lived in a remote, hilly village. She became pregnant soon after and did not have any problems in early pregnancy. During one of her occasional visits to the village, the Auxiliary Nurse Midwife gave her a shot of Tetanus Toxoid and a few iron tablets. This was the only time in her entire pregnancy that Bamai met a health worker. The night she had labour pains, the Group members disseminated stories about pregnancy and delivery during community meetings on at least four occasions during the cycle. During the 3-year study period, facilitators and members narrated an estimated 976 new stories. This enabled women and the wider community to discuss cause and effect linkages, but also some of the more distal causes of health problems. This is important since one of the theoretical premises of the intervention is that behaviour change will occur if communities are able to analyse the cause and effect linkages of health problems, and then define ways in which they can influence these linkages. In the final stages of this process, communities would ideally understand both upstream and downstream determinants of health, identify the political and economic roots of ill health, and challenge actors responsible for perpetuating these. Writers such as Freire described this as the development of 'critical consciousness', or the process through which individuals and groups become conscious of the oppressive systems and actors that maintain some in poverty and ill health  We suggeTwo additional features of the intervention built on the participatory principles inherent to the women's group intervention but were unique to the Ekjut trial in their intensity and focus: the involvement of the wider community, including local community health workers, and the active targeting of marginalised groups and pregnant women. Group members garnered support for maternal and newborn health issues beyond the groups by actively involving the wider community in discussing their problems and strategies. This was done in three main ways. First, most of the groups were initially closed because they dealt with micro-credit activities, but, with the addition of the participatory cycle, groups became open to all community members and men, relatives of pregnant women and frontline government workers were free to attend. Second, members shared their problems and strategies with the wider community during village and cluster-level meetings. Third, community members, including men, offered support in the implementation of the groups' strategies. At the last meeting, an estimated 70% of group attendees were married women of reproductive age, 7% were men, and 23% were adolescent girls or unmarried women. Figure The groups' inclusiveness meant that different community members and decision-makers present during deliveries were likely to have attended meetings and therefore have increased awareness of maternal and newborn health issues. We reviewed several case studies highlighting the impact of groups on different community members and the consequences of this for health outcomes, and chose the following as illustration:th month of pregnancy. Her husband, who had attended some of the women's group meetings held in their village, asked her to go for a checkup because he knew it was a serious problem. When she refused, saying that it would be fine after she delivered, he asked a women's group member to convince her to go for treatment and they pressurized her to go for check-up during the ANM's visit. At the time of her delivery, she used the homemade delivery kit she had prepared. She delivered twins and did not bathe her babies, but instead wiped and wrapped them. After a few days, when she saw that another woman in the village also suffered from swollen face and legs, she accompanied her to the nearby Primary Health Centre. At the time of her delivery the group members took the initiative to convince her husband to have an institutional delivery and provided monetary support for taking her to the primary health centre, where she delivered normally.Sonia Munda suffered from swollen face and legs during her 8The Ekjut trial surveillance data showed that over 37% of home deliveries in the study area were conducted by family members, including mothers-in-law, husbands, relatives and neighbours, so it is likely that group members or their relatives managed deliveries using information and skills from the meetings. Group members themselves became active health advocates in the community. In our surveillance data, members recalled making home visits, arranging transports for emergencies, providing financial help from the group's emergency fund (even to those who were not part of their savings groups), and counselling relatives of pregnant women. In total, members recalled providing assistance to 3822 pregnant women during the study period.Women's group members described a progressive increase in community mobilisation to deal with health problems. They were able to make Auxiliary Nurse Midwives and Anganwadi Workers community health workers more accountable as these workers attended the meetings. The groups and their activities may also have catalysed community mobilisation and capacity beyond the health domain. The following quotes were selected during data analysis to illustrate this process:As for my knowledge, the people who are attending the meetings and discussing many new things about the health of mothers and newborns are explaining what they have learnt to five more people, as a result of which each and every person should know. These meetings are really helpful as we are only involved in trying to solve the health problems of the community through the help of community members. We believe that together we can bring about change. We used to live on our own, only concerned about our family well being, and others also used to only see their own interest. But now, as we are sharing and discussing our issues, we have developed a sense of bonding with each other and are helping each other in times of need. In addition to its acceptability, its participatory approach to the development of knowledge, skills and 'critical consciousness', and the emphasis on community involvement beyond the groups, the Ekjut intervention had three further unique characteristics. First, the intervention team actively sought to work with the poorest communities in the study areas. Ekjut elected to work with existing PRADAN groups, an NGO primarily serving marginalised tribal areas. Ekjut also explicitly targeted areas that were predominantly inhabited by tribal people who had no or little land holdings, low literacy rates, and with many living below the poverty line. While 28 and 22% of the population in Jharkhand and Orissa are tribal, over 70% of women present in the first and last meeting of the Ekjut learning action cycle were tribal people. Ekjut also set up new groups in hamlets, which have poorer access to community health workers and health services than villages.Second, the intervention team, facilitators, and group members invited pregnant women to join groups. Indeed, we observed that the attendance of pregnant women at group meetings increased over the three-year study period. During the first year, 18% (n = 546) of the women who delivered a baby attended Ekjut groups. This number increased to 38% (n = 1287) in the second year and reached 55% (n = 1718) in the third year.Finally, the intervention had relatively high population coverage. In the Ekjut trial, the coverage of women's groups was 1 group per 468 population, compared with 1:756 in the Makwanpur trial and 1:1414 in a similar trial in Bangladesh, which did not yield a reduction in newborn mortality. We might therefore hypothesise that the Ekjut intervention had a significant impact on neonatal mortality because the key intervention characteristics described above were operationalised with local adaptations, the intervention had an adequate population coverage and high enrolment of pregnant women, the neonatal mortality rate was relatively high and a high proportion of neonatal deaths occurred at home.dais) in the implementation of strategies, as some felt the contents of meetings went against traditional beliefs and practices. Despite these challenges however, all 244 groups completed the intervention cycle and members' attendance was maintained at more than 70% throughout the cycle.The intervention team and group members faced several challenges. The team initially experienced difficulties in building a rapport with marginalised tribal communities and dealing with expectations of financial gain. Facilitators contended with dominant group members and cancellations during festivals and cultivation periods. They also managed the presence of men during sensitive discussions as well as rare disruptions from non-group members. They also had to ensure participation even during internal conflicts within villages. Group members were sometimes constrained by in-laws and TBAs  framework for the evaluation of complex interventions argues that "complex interventions may work best if tailored to local circumstances rather than being completely standardized" . We hypoCommunity mobilisation challenges existing models of public health intervention delivery: mobilisation through groups is not a discrete intervention where impact is delivered linearly from implementers to recipients. Instead, implementers, facilitators, group members and community members are all in turn 'designers', 'implementers' and 'recipients' of learning and change. The recognition that all these participants can and must contribute is critical to trust, and thereby to behavior change. This cyclical learning process is different to methods used in traditional health education or even 'behaviour change communication' models, but must be understood and respected by implementing organizations in order to support community mobilisation in the face of multiple local and external challenges. The model also challenges existing community interventions to improve maternal and newborn health outcomes, many of which rely largely on home visits by community health workers and involve communities mainly through awareness raising meetings.Can and should community mobilisation approaches be replicated and scaled-up to improve maternal and newborn health? We believe that they should, in combination with appropriate outreach and health services strengthening activities. The Ekjut and Makwanpur studies have shown that interventions building on community mobilisation are effective in high mortality settings where a high proportion of deaths occur in the community from causes such as sepsis and hypothermia. This impact may be more difficult to achieve in settings where further mortality reduction is largely dependent on improvements in health service access and quality, in particular emergency obstetric care, but where structural factors hinder communities' ability to act on these. The intervention can be a complement to other models, including home visits, which have impacted on mortality in studies such as the Shivgarh and Projahnmo trials ,22. For The Ekjut trial is an example of a successful participatory intervention that has shown a tangible impact on seemingly intractable health outcomes. Participatory community mobilisation interventions may influence maternal and child health outcomes if their key intervention principles are preserved and tailored to local contexts. Scaling-up this community mobilisation intervention will require a detailed understanding of the way in which changing contexts, delivery mechanisms, and implementation styles will affect key characteristics of the intervention. If combined and locally tailored, community mobilisation, improvements in health services, and the involvement of community health workers have the potential to yield lasting change for mothers and newborns.The authors declare that they have no competing interests.SR and AP wrote the first draft of the paper and coordinated all subsequent inputs. SR, NN, PT and AP contributed to the data analysis. SB, SR and NN designed the process evaluation protocol for the Ekjut trial. All authors contributed to the final analysis and recommendations.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-698X/10/25/prepub


Road traffic injuries are a major public health problem, especially in low- and middle-income countries. Post-crash management can play a significant role in minimizing crash consequences and saving lives. Iran has one of the highest mortality rates from road traffic injuries in the world. The present study attempts to fill the knowledge gap and explores stakeholders' perceptions of barriers to – and facilitators of – effective post-crash management in Iranian regions.Thirty-six semi-structured interviews were conducted with medical services personnel, police officers, members of Red Crescent, firefighters, public-health professionals, road administrators; some road users and traffic injury victims. A qualitative approach using grounded theory method was employed to analyze the material gathered.The core variable was identified as "poor quality of post crash management". Barriers to effective post-crash management were identified as: involvement of laypeople; lack of coordination; inadequate pre-hospital services; shortcomings in infrastructure. Suggestions for laypeople included: 1) a public education campaign in first aid, the role of the emergency services, cooperation of the public at the crash site, and 2) target-group training for professional drivers, police officers and volunteers involved at the crash scene. An integrated trauma system and infrastructure improvement also is crucial to be considered for effective post-crash management.To sum up, it seems that the involvement of laypeople could be a key factor in making post-crash management more effective. But system improvements are also crucial, including the integration of the trauma system and its development in terms of human resources (staffing and training) and physical resources as well as the infrastructure development. Road traffic injuries (RTIs) are a major public health problem, requiring concerted efforts , in the PCM leaves much to be desired especially – but not exclusively – in low-and middle-income countries ,12,16. IStudies in the field performed in settings other than Iran have used mainly quantitative designs that have helped to quantify needs more than to obtain new perspectives. The few in-depth qualitative studies available -27 have The study was performed using Grounded Theory, which is a suitable method when new areas are to be investigated in an explorative manner or if it has been decided to explore a known area from a fresh perspective ,34,35.2, and the population density is 77 inhabitants/km2. In 2005, the total number of fatal road traffic injuries reached 1,018, i.e., 34 per 100,000 of the population [Focus was placed on PCM for road traffic injuries that occurred in West Azarbaijan Province (WAP) and Tehran; both local and national stakeholders were interviewed. The province covers an area of 37,411 kmpulation .In Iran, Emergency Medical Services, the police and the fire brigades can all function as emergency services and take care of victim management when road traffic crashes occur. People can contact them by dialling the three-digit numbers 115, 110 and 125, respectively. Additional potential actors include different ambulance services and the Red Crescent, whose activities are primarily focused on rendering relief to the victims of natural and man-made disasters in general  but who Stakeholders of varying experience and knowledge, representing different perspectives on PCM, were approached for interviews. A few victims were also interviewed because of the unique perspective they could add on what takes place at the crash scene. The number of participants was determined based on saturation principles . From thData were gathered through semi-structured interviews beginning with general questions, gradually progressing to more specific ones. Probing was performed according to the reflections of each participant, concerning prior experiences of the post-crash event; perception about barriers to PCM; opinions about facilitators of effective PCM; opinions relating to the role of laypeople at crash scenes; opinions about the organization and coordination of PCM. The interviews lasted between 45 and 80 minutes. They were conducted between March and December 2007.Finding and contacting eligible participants was made easier by the fact that the principal investigator had experience in the domain, having worked with the management of road traffic injury victims. The interviews were conducted in Persian, transcribed verbatim and summarized in English, and two interviews had read by a researcher who was not a Persian speaker. The rest of the researchers were fluent in both Persian and English.The interview transcriptions were compared with the recorded digital files for accuracy. The data gathered were analyzed following the principals put forward by Strauss and Corbin ,35, i.e.The study was approved by the National Ethics Committee of Iran . Intervi"Poor quality of post crash management" was the core variable, which mirrored the general views expressed by the participants. Four maThe involvement of untrained laypeople as a potential barrier during post-crash events was mentioned by all participants. The main factors identified concerned cultural background, limitations in knowledge and late arrival of the emergency services. Altogether, these factors explain why laypeople gather at a crash scene, the negative effect of their role in rescue activities and how they have the potential to indirectly increase injury morbidity and mortality. Figure The cultural background factors relating to laypeople's involvement that were raised during the interviews included: a willingness to help, humanitarian assistance, individual curiosity, people's sense of haste, excitement, and disorganized cooperation (leading to a crowded crash scene and poor coordination). It was also mentioned that laypeople feel that removing victims from the crash scene and taking them to hospital quickly is better for the victims. Laypeople's limited knowledge related to: how to interact at a crash scene; what information needs to be given to the emergency service; how to use different emergency numbers; and how to provide first aid. Whereas all participants commented on the above, professionals in the EMS and police officers pointed out that such knowledge limitations affected the quality of the information provided (incomplete or wrong) to the emergency services. Police officers, representatives from the Road & Transportation Office and some victims added that laypeople's worries about whether ambulances would arrive on time also influenced the quality of the interactions.(EMS/1)People want to help casualties, but they usually don't know first aid, aren't sure what to do before the ambulance arrives and what kind of detailed information they need to give the emergency services when they call them. This can lead to incorrect phone-calls and the wrong information being conveyed.Invariably, laypeople are the first to arrive at a crash site. According to most stakeholders, laypeople are often stressed and can easily interfere with the activities of ambulance personnel. They usually remove victims too quickly and take them to hospital in their vehicles. Their involvement is regarded as necessary to alert the emergency services and seen as useful in rural and remote areas. However, members of the EMS and police officers consider that laypeople, when too involved in crashes occurring in urban areas, may easily contribute to wasted time, hamper the emergency services, cause secondary injuries to victims and even provoke new crashes.(PO/3) A common problem at crash scenes is the gathering of too many people and their emotional behaviour, which could at worst lead to new crashes and new injuries to the victims. (EMS/2) An example of the latter might be potential spinal cord injuries caused by the victim being moved too fast.Different opinions were gathered concerning crash management and delayed victim transport. At many crashes, the police must be present to take statements, which is important for insurance and legal purposes. According to EMS members, this task wastes precious time and delays the transportation of victims to hospital. Members of other organizations stated that an insufficient number of ambulance dispatch sites could also result in delayed transportation. Moreover, the fact that rescue activities are designed in different ways in different organizations could contribute to delays. Additional factors seen as likely to impede coordination were: lack of a systematic approach to PCM; different ambulance dispatch site locations; existence of parallel organizations with the same activity ; substandard telecommunication equipment; and undeveloped satellite navigation (GPS), which might hamper coordination and cooperation among the organizations.(EMS/2) Most of the calls made by laypeople to the emergency services or other organizations concern crashes without casualties. We dispatch our ambulance but since there are no casualties, it is a waste of both time and resources...The low number of ambulance dispatch sites is viewed as a hindrance to effective pre-hospital services, together with inadequate human resources  and insufficient physical resources (ambulances and their equipment). Some participants stated that the role of a rescuer in post-crash events of road traffic injuries is not clear, and is established differently in different organizations. There is often a lack of police officers at many crash scenes and their lack of crash scene management skills was also seen as a hindrance to effective PCM.(PO/3)The fire services are officially responsible for rescue activities particularly in urban area, but they cannot be present at all crashes. However, EMS ambulances usually don't have enough rescue equipment and in some cases, crash victims are trapped in their cars, resulting in the EMS having to call the fire services to come and cut them out.Some participants in EMS, public health organizations and police officers stated that shortcomings in the infrastructure constitute an important barrier to effective PCM. These include poor urban infrastructure and no satellite navigation (GPS) or well-established telecommunication systems.(EMS/5) There is not usually a traffic lane reserved for the emergency service, and we are stuck in a traffic jam... (RT/2) there are different emergency numbers for organizations and people will be confused over which number they should call when they see a crash and an emergency situation.All participants stated that public education plays an important role in effective PCM and considered it should be widely spread. It was mentioned that, in recent years, many activities and public education campaigns have been implemented by the police, focusing on the primary and secondary prevention of road traffic injuries, but the need for more public education regarding PCM was clearly stressed. It was considered that this should incorporate aspects related to better cooperation of people with the emergency services, basic first aid techniques, the role of the different emergency services in road traffic crashes, as well as safe victim transportation when ambulances are not available. All participants pointed out that the mass media, especially television, were relevant channels of public health information in the Iranian context. On the other hand, it was strongly felt that, since many people still do not have enough knowledge of first aid, their cooperation should be limited to protection of the crash scene and alerting the emergency services, especially at urban crash sites. Their cooperation should also be under the supervision of members of the emergency services.(PO/1) People need to learn that they should leave the crash scene immediately when the ambulance team arrives. (EMS/4) Public education is necessary for first aid, recognizing emergency needs, helping the ambulance arrive faster and leaving the crash location carefully and calmly. (PO/1) They should know how to use the different emergency numbers to call the appropriate emergency service.Most participants stated that training of those who arrive initially at the crash scene was another way of improving crash scene management. The fact that, in Iranian culture, those who help others are held in high esteem, can be beneficial when it comes to PCM. It was proposed that training should include basic principles of safe rescue, Cardio Pulmonary Resuscitation (CPR), victim triage and safe transportation to medical centres. This group could be made up of professional drivers. The same suggestion was made with regard to other people who volunteer their help. Providing a kit of simple equipment and supplies and a special uniform for this group could improve their cooperation. Some participants also recommended an ongoing pilot programme, in which police officers receive special training on how to manage crash sites.(RT/2)If we can train some professional drivers  and if we give them a uniform to show that they are responsible for emergency services as well as some supplies, this might improve crash scene management. (PO/2) Such people are often first on the crash scene, arriving sooner than all other organizations, and if they know first aid and preliminary crash scene management, they will be of more help to the victims.Combination of rescue activities and the introduction of one emergency telephone number were suggested by most participants. Further, better coordination among organizations was regarded as necessary for effective victim management. It was proposed that all EMS ambulances and Red Crescent ambulances should be equipped with rescue equipment, as well as other vital equipment. Moreover, in order to improve victim rescue, staff training was seen as more important than physical equipment, including the number of ambulances and ambulance dispatch sites. One suggestion for interurban roads was the establishment of a collaborative group consisting of ambulance team members, Red Crescent personnel, police officers and road & transportation officers, which would be more useful in crash black spots. Access to a helicopter ambulance in crowded cities was also regarded as necessary. Both these last two suggestions are currently being implemented in many cities and need to be expanded.(EMS/2) Should a system be formulated to do the tasks of police, firefighters, medical staff and rescue teams, all together, (if so) the provision of services would be much better... (FF) if emergency services can have a single emergency number for all calls, it could ease coordination and speed up arrival on the crash scene. , the rolThis, in turn, calls for better public information concerning what should preferably be done by laypeople at the crash scene . Such information should also point out the important role that trained laypeople can play when, among other things, applying first aid e.g., checking the victims' airways, bleeding and circulation , and beiAn additional educational aspect to be dealt with is the training of target groups. Indeed, studies from low-and middle-income countries indicate that basic first-aid training for professional drivers  could help improve PCM, as they can often provide care and transportation ,41,42. TAccording to Nathens et al. , the traThe vast majority of road traffic deaths in low-and middle-income countries ,47 and iAlthough rapid improvements in pre-hospital care services have occurred in the country , it seemThis interview-based study gathers the opinions of various actors relating to the barriers to and possible facilitators of effective PCM in the Iranian context. As such, it is one of the few studies adopting a qualitative approach to highlight ways of improving the current situation. The results point to a number of crucial areas in need of improvement, and for which some strategies have been proposed.As is the case in qualitative studies, the number of participants was relatively small, but all stakeholders were experienced and knowledgeable and saturation was reached. The data was even validated using constant comparison analysis, which means returning to the data in order to verify and develop the categories further. In this vein, the input from previous victims can be regarded as an important contribution – and an originality of the study.Because of our design, the generalizability of these data is not self-evident. It would definitely be of interest, however, to see the extent to which future research in the same field, but from other parts of the country, yielded similar result.Improving PCM helps reduce deaths, disability and the severity of road traffic injuries. The study sheds light on important barriers to effective PCM that need to be tackled in the Iranian context, including the involvement of laypeople, insufficient pre-hospital services and poor coordination. Among other recommendations for laypeople in general, the suggestions gathered include public education campaigns, covering the use of emergency numbers, the role of organizations in crash site management, first aid, better cooperation between laypeople and ambulance personnel and other organizations, and preliminary management of the crash scene before the arrival of the ambulance. Police officers and professional drivers are also an important target group, as their role can be very influential in crash scene management. Their training could cover management of the crash scene, including securing the scene to prevent new crashes and applying first aid for victims before the ambulance arrives, triage of the victims as well as their safe transportation.Despite improvements in pre-hospital care, the upgrading and improvement of physical resources should also be considered, including improvement in ambulance dispatch sites and their equipment as well as staff. More focus needs to be put on their training and skills. Supplying all ambulances with rescue equipment is strongly recommended. Moreover, improvements to telecommunication systems need to be seriously considered. Furthermore, instead of different pre-hospital services, an integrated trauma system should be considered as a long-term strategy with a focus on research.The authors declare that they have no competing interests.DKZ has made substantial contributions to the conception and design of the study, and taken responsibility for and coordinated the acquisition of data, which he gathered and analyzed. He took part actively in the analysis of the data, in its abstraction and in the writing-up of the manuscript. HRK and LL contributed to the conception and design of the study. HRK was involved in the data collection process and took an active part in the data analysis and results interpretation. LL also took part in the writing-up and finalisation of the manuscript. RM, AB and BH contributed to the study design, data acquisition, results interpretation and writing-up of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


The biological behavior of endometrial carcinoma differs in epidemiology, presentation, and prognosis, suggesting that there are two fundamentally different pathogenic types of disease: type I  and type II . Untreated hyperplasia can develop into an endometrioid type of adenocarcinoma, hence, it is important to recognize the former type. In contrast to cervical cancers, there are limited studies with respect to the biology of hyperplastic lesions documented from India. This was a 16-year retrospective study, carried out to determine the nature and outcome of proliferative lesions of the endometrium in a referral center from south India.A histopathological diagnosis of the endometrial hyperplasia, polyp, and carcinoma, on endometrial biopsy and hysterectomy specimens, over a 16 year period (1983 to 1999), were recorded in a computer and the case slides were reviewed. Using the computer software Foxpro, the patients who had come more than once for a subsequent or previous biopsy were identified. An attempt was made to look for progression, regression or a static nature of the lesion in the follow-up cases.A total of 1778 cases were studied, and only 74 patients with endometrial hyperplasia and five cases of benign endometrial polyp had follow-up endometrial histopathology. Hyperplasia cases included 59 cases of simple hyperplasia, 10 cases of complex hyperplasia without atypia, and five cases with atypia. The predominant age for patients with all types of hyperplasias was 41 – 50 years. Progression to a higher grade was seen in 8.10%, regression to a lower grade was seen in 9.45%, lesions reverted to a normal pattern in 10.81% cases, and lesions persisted in 70.27% of the cases. A mixed pattern was seen in 54 cases, with predominant coexistent lesion being simple and complex hyperplasia without atypia.The fate of the hyperplastic lesion of the endometrium showed a varied pattern. Follow-up cases predominantly showed persistence of the lesion, possibly resulting from a fluctuating but higher level of estrogenic stimulus. Hence, it was not only the high levels of estrogen that influenced the biology, but its sustenance for a prolonged period. It was Recamier in 1850, who first recognized the condition of endometrial hyperplasia. For manyAlmost 59 years ago, Hertig and Sommers, proposed the theory of progression of endometrial hyperplasia to adenocarcinoma, going through a stage of atypical changes. AdenomatEndometrial biopsies or hysterectomy specimens with diagnosis of endometrial hyperplasia, endometrial polyp, and adenocarcinoma, from 1983 to 1999, were included in the study. The details of patients included in this study were derived from the histopathology requisition files and recorded in a structured proforma, which was then fed into the computer. Using the Foxpro software, patients with more than one endometrial biopsy or who had subsequent hysterectomy were identified. The histopathological status of the endometrium was reviewed and correlated with the clinical history and an attempt was made to look for progression, regression or a static nature of the lesion.The endometrial hyperplasias were classified according to the World Health Organization (WHO) classification, as simple hyperplasia without atypia (SH), simple hyperplasia with atypia (SHA), complex hyperplasia without atypia (CH), and complex hyperplasia with atypia (CHA).A total of 1778 cases of endometrial hyperplasia / polyp / carcinoma were studied. Out of these only 74 patients with endometrial hyperplasia and five cases of benign endometrial polyps came for subsequent follow-up. Patient with endometrial hyperplasia under follow up included 59 cases of SH , 10 caseFifty -four cases out of the 1778 cases in this study showed a mixed pattern of lesion . One casIn the study, the age of patients with endometrial hyperplasia ranged from 12 to 80 years. The mean age of the patients with SH was 39.13 years, whereas, for CH it was 39.99 years, and 42.15 years for CHA . The treEndometrial carcinoma is the most common malignant tumor of the female genital tract in developed countries. The differences noted in epidemiology, presentation, and biological behavior of endometrial carcinoma suggest that there are two fundamentally different pathogenic types of the disease: type I  and type II . Type 1 eet al. also documented this to be the most common age group for SH.[Patients with hyperplasia have anovulatory menstrual cycles; some of them may be on exogenous estrogen. Although anovulatory cycles occur at menarche and in postmenopausal women, hyperplasia is not usually encountered in younger women, probably because bleeding in menarchial women is seldom evaluated by an endometrial biopsy. In the present study, the minimum age of presentation was a 12-year-old child with SH. She was younger than the one reported in literature. The mostp for SH. Endometrp for SH.et al., in 1961, observed that the cumulative risk of developing endometrial carcinoma for a patient with AH for 9 to 10 years is significantly higher than for women without hyperplasia.[The relationship between hyperplasia and carcinoma has been an actively debated subject. Several studies have demonstrated a close relationship of endometrial hyperplasia and carcinoma. Gusberg erplasia. McBride erplasia.et al. also found a high percentage of regression including cases with features of atypia. However, they found only one case that progressed to adenocarcinoma.[et al. and Kurman et al, also showed a higher percentage of regression as compared to ours, this may be due to the reason that most of the patients in their follow up were being treated with progesterone.[The fate of a hyperplastic lesion of the endometrium in the present study showed a varied pattern. Tabata arcinoma. Studies esterone.15 Our stet al. 1985, found that an average period of 4.1 years was needed for atypical hyperplasia to develop into carcinoma.[Kurman arcinoma. About 17arcinoma. One casearcinoma.The numbers of prospective studies have been small and the true natural history of the disorder could not be observed due to the administration of various forms of therapies. Retrospective studies may on the other hand give a biased and unduly gloomy view of the risk of adenocarcinoma.Endometrial hyperplasia of whatever type must be considered as a warning sign that an endometrium is noncycling and therefore susceptible to neoplastic events. The mere presence of hyperplasia is not a basis for hysterectomy. However, in general, the more severe the hyperplasia the more likely it is to be followed by invasive carcinoma. Timely treatment can help to provide an environment for the lesion to regress and avoid radical surgeries. Several investigators have found beneficial effects from treating hyperplasia and carcinoma with progesterone. Kistner, treated patients with atypical hyperplasia and patients with carcinoma in situ with progesterone and found that the lesions were reversible and none advanced.All forms of hyperplasia in the endometrium appear to be the result of excessive stimulation by estrogen, although such an association is somewhat clear for cystic hyperplasia than it is for atypical hyperplasia. It would44However, an alternative explanation could be that the two types of hyperplasia develop concurrently; variable effect being the result of the difference in response from one area of the endometrium to another. In this Endometrial polyps are a common cause of abnormal uterine bleeding. Rarely, is hyperplasia, either a complex or atypical type, identified within a polyp, in a biopsy or polypectomy specimen. Currently, it is not known whether the hyperplasia is likely to be confined to the polyp or also involves a non-polypoid endometrium.et al, a low prevalence of premalignant and malignant lesions in endometrial polyps were found.[et al. documented in their study that the risk of endometrial hyperplasia in a polyp, concurrently involving a non-polypoid endometrium was significant.[In our study, we had very few cases to assess this possibility, though we found progression to SH in one case, and a mixed pattern with SH and CH in 12 cases. This could draw our attention to the chances that all were related to each other. In a study done by Antunes re found. Their stre found. Kelly etnificant.The nature of the disease was such that patient would require several consultations. Although this was a retrospective study for a period of 16 years, there were limited patients who came for subsequent follow up at our center. Hence, there were chances that the traceability of patients had been lost either because they had lost their out-patient identity card and had re-registered at our center with a new identity number or had gone to a different centre for subsequent visits.The biological behavior of hyperplasia and the coexistence of various subtypes of hyperplasia along with carcinoma suggest the possibility of a single disease spectrum. In our study, a majority of the cases showed persistence of lesions, with regression and progression in a few cases. This could partly be due to either sustained increased levels of estrogen or a fluctuating high and low levels. This highlights that the levels of estrogen could play a major role in influencing the disease biology and outcome. Further studies correlating to the levels of estrogen and disease progression will provide a deeper understanding. An integrated approach needs to be designed in the healthcare delivery system, with a unique identity number, for maintaining traceability and follow-up of cases for treatment and research purposes. Timely recognition, regular follow up and relevant treatment can prevent disease progression.


The planning and assessment of malaria interventions is complicated due to fluctuations in the burden of malaria over time. Recently, it has been reported that the burden of malaria in some parts of Africa has declined. However, community-based longitudinal data are sparse and the reasons for the apparent decline are not well understood.Malaria prevalence and morbidity have been monitored in two villages in north-eastern Tanzania; a lowland village and a highland village from 2003 to 2008. Trained village health workers treated presumptive malaria with the Tanzanian first-line anti-malarial drug and collected blood smears that were examined later. The prevalence of malaria parasitaemia across years was monitored through cross-sectional surveys.The prevalence of malaria parasitaemia in the lowland village decreased from 78.4% in 2003 to 13.0% in 2008, whereas in the highland village, the prevalence of parasitaemia dropped from 24.7% to 3.1% in the same period. Similarly, the incidence of febrile malaria episodes in the two villages dropped by almost 85% during the same period and there was a marked reduction in the number of young children who suffered from anaemia in the lowland village.There has been a marked decline in malaria in the study villages during the past few years. This decline is likely to be due to a combination of factors that include improved access to malaria treatment provided by the trained village helpers, protection from mosquitoes by increased availability of insecticide-impregnated bed nets and a reduced vector density. If this decline in malaria morbidity is sustained, it will have a marked effect on the disease burden in this part of Tanzania. There have been previous efforts to eradicate or, if this was not possible, to eliminate malaria, but these ambitious goals have not been achieved in large parts of Africa -5 despitAnopheles gambiae is the most prevalent vector in the lowlands, while Anopheles funestus predominates in the highlands. In previous studies, entomological inoculation rates (EIR) have been reported to be more than 100 in the lowlands, but less than 30 infective bites per person per year at intermediate altitudes. In the highlands, mosquito densities are too low to allow reliable EIR measurements, but an EIR of 0.03 infective bites per person per year has been extrapolated  up to 2006 and artemether-lumefantrine [ALu] from 2007 to date), paracetamol, slides, blood lancets, gloves, treatment charts, febrile case detection forms and storage boxes. CORPS were instructed how to collect blood smears under aseptic technique and to preserve these until collected by a team of supervisors composed of a clinical officer and a laboratory technician. CORPS were also instructed on how to treat patients with the first-line anti-malarial drug and an antipyretic, and how to refer patients who had severe symptoms or who did not respond adequately to the first-line anti-malarial treatment to Korogwe District Hospital. Villagers were informed that they could call on the CORPS at any time if they had symptoms of malaria. From suspected malaria cases, the CORPS would then collect basic clinical data, obtain a blood smear for malaria microscopy and institute presumptive malaria treatment. Patients with severe symptoms or symptoms suggestive of other diseases than malaria were referred to the local dispensary or the District Hospital.Malaria cross-sectional surveys were conducted in the two study villages from 2003 to 2008 Table . The sur® photometer . Whole blood was used to prepare thick and thin blood smears for malaria microscopy. These were stained with 10% Giemsa stain for 15-20 minutes after fixing thin smears with methanol. Asexual and sexual parasites were counted against 200 and 500 white blood cells, respectively. The differentiation of malaria parasite species was confirmed by microscopy of thin smears. A blood smear was declared negative only after examination of 200 high power fields. The density of asexual parasites was calculated assuming 8,000 leucocytes per μl of blood and expressed as parasites per μl. Slides were red retrospectively and during surveys malaria treatment was only given to patients complaining of malaria symptoms.Five millilitres of venous blood were collected from individuals aged three years or more. For children below three years, 300-400 μl of capillary blood was obtained by finger prick into an Eppendorf tube containing EDTA. The haemoglobin (Hb) concentration of each participant was measured using a HemoCuePlasmodium falciparum parasitaemia of any density. The summary measures consisted of percentage for categorical variables and means for continuous variables. Incidence was calculated as documented number of febrile malaria episodes to the population size in each age group and/or village per year.All data were double-entered into a Microsoft Access database, cleaned, validated and transferred into Stata version 9  and R 2.7.0 for statistical analysis. Fever was defined as an observed axillary temperature of ≥37.5°C and/or a history of fever within the previous 24 hours. A febrile malaria episode was defined as an episode of fever with a positive blood smear for asexual Plasmodium falciparum, parasiteamia across the years, number of individuals with parasitaemia during cross-sectional surveys were modelled as a binomial random variable using logistic regression. The model was fitted for each village separately and was adjusted for the effect of age and use of bednets. To compare the risk of Plasmodium falciparum infection between the two villages, a similar model was fitted for the two villages. In addition, linear regression models were used to determine the changes in mean haemoglobin (Hb) concentration across years and effect of Plasmodium falciparum parasiteamia and season on Hb levels while controlling for age and reported use of insecticide-treated or non-treated bed nets. In this model the effect of year was fitted as a categorical variable. A statistical significance level was considered at P-value < 0.05.In modelling the risk of Ethical clearance was granted by the Medical Research Co-ordinating Committee of the National Institute for Medical Research, Tanzania. Prior to the study, meetings were held with local authorities and with the villagers in each study village, during which the aims of the study were explained. Informed consent documents for the study were prepared in English and translated into Kiswahili before administration to both village leaders and participants. Written informed consent to participate was obtained from each study individual or from his or her parent or guardian. Villagers were free not to participate in the study without giving any reasons, or being disqualified from any medical services that were provided to all villagers throughout the study period. Feedback to the village has been performed continuously during the study.P. falciparum was detected in 78% and 25% of the residents of lowland and highland villages, respectively. In the subsequent cross-sectional surveys conducted each year, the prevalence of P. falciparum decreased steadily in both villages as shown Figures P. falciparum infection was higher in residents of lowland village, OR = 12.28  compared to highland village. The risk of infection decreased by year, with an OR of 0.564  and 0.660 , per year compared with the baseline, for lowland and highland villages, respectively. The decline in the point prevalence of parasiteamia was seen in all age groups in both villages . When the effect of the use of bed nets was assessed in each village separately, it was found that the use of bed nets was not associated with a reduction in the risk of malaria parasitaemia in highland village , but was significant in lowland village .The age specific incidence of malaria episodes by village is shown in Figure Plasmodium falciparum parasitaemia was associated with a lower mean haemoglobin concentration (Table The mean haemoglobin concentration of individuals living in highland village was higher than that of those living in lowland village. In highland village, mean haemoglobin concentration was highest in 2003, whereas in lowland village it was the lowest in this year. Similarly, the mean haemoglobin concentration of children aged 0-3 from lowland village was markedly lower in 2003 than in the following years Figure . AdjustiThis community based study assessed the malaria burden in two villages in Korogwe district, north-eastern Tanzania by collecting data in repeated cross-sectional surveys and by employing CORPS to monitor malaria morbidity over six consecutive years. In this study, lowland residents had almost a twelve-fold increase in the risk of malaria parasitaemia compared to their counterparts in the highland village. At the start of the study, the lowland village could be categorized as high transmission whereas transmission in the highland village could be categorized as moderate. During the six years of the study, there was a marked and progressive decline in the malaria burden and this was reflected in the point prevalence of parasitaemia, the incidence of clinical episodes of malaria and in the mean haemoglobin concentration.It is well established that immunity to malaria is a function of age, and that in areas of high transmission the malaria burden mainly is carried mainly by children and infants, while in areas of low transmission, all age groups are affected . As malaDuring the study, the malaria burden also decreased among inhabitants of highland village and among the older age groups in lowland village, but because the decline in burden was more pronounced among the young children in lowland village, the net effect was that, at the end of the study the malaria burden appeared to be more equally distributed among the different age groups. During the study, many cases of severe malaria were not documented. This is probably due to the fact that a relatively low number of individuals were surveyed, and that these individuals had access to prompt and effective treatment. Thus, how the decline in transmission has affected the incidence of severe malaria in its different manifestations could not be estimated. This, is an important question as cerebral malaria has been reported to affect slightly older children than those affected by severe anaemia, and a declining incidence might lead to an increase in this severe form of malaria ,26.Other studies mainly based on data collected at health facilities have documented that malaria transmission seems to be falling in other parts of East Africa and in some of these studies the decrease has been attributed to specific interventions -18. In tThere is no simple explanation for the decline in malaria in the study villages, and it is rather an unsatisfactory situation of having to assign this to a combination of different factors such as climatic changes, better health provision, increased coverage of bed nets and socio economical development. It is very important to establish the relative contribution of these and other factors to the decline in malaria, as this will shed light on the risk that malaria might strike back. Entomological studies in the study villages were not done during the study period and whether there have been changes in mosquitoes distribution across years is not established.In conclusion, there has been a dramatic progressive decline in point prevalence of malaria in the study villages during the study period, and in parallel the malaria disease burden has fallen, especially among those most affected previously, the infants and young children living in the village where malaria transmission was high previously.The authors declare that they have no competing interests.All authors were involved in the design of the study. LV, BM, AK, ML, TT and JL conceived the study. BM, LV and JL and were responsible for the implementation of the study in the field. BM coded the data and supervised data entry. BM and JL analysed data. JL wrote the first draft of the manuscript. All authors were involved in revising the manuscript, and read and approved the final version.


The balance of the benefits and risks of long term use of hormone replacement therapy (HRT) have been a matter of debate for decades. In Europe, HRT requires medical prescription and its advertising is only permitted when aimed at health professionals . The objective of this study is to analyse the appropriateness and quality of Internet advertising about HRT in Spain.A search was carried out on the Internet (January 2009) using the eight best-selling HRT drugs in Spain. The brand name of each drug was entered into Google's search engine. The web sites appearing on the first page of results and the corresponding companies were analysed using the European Code of Good Practice as the reference point.Five corporate web pages: none of them included bibliographic references or measures to ensure that the advertising was only accessible by health professionals. Regarding non-corporate web pages (n = 27): 41% did not include the company name or address, 44% made no distinction between patient and health professional information, 7% contained bibliographic references, 26% provided unspecific information for the use of HRT for osteoporosis and 19% included menstrual cycle regulation or boosting feminity as an indication. Two online pharmacies sold HRT drugs which could be bought online in Spain, did not include the name or contact details of the registered company, nor did they stipulate the need for a medical prescription or differentiate between patient and health professional information.Even though pharmaceutical companies have committed themselves to compliance with codes of good practice, deficiencies were observed regarding the identification, information and promotion of HRT medications on their web pages. Unaffected by legislation, non-corporate web pages are an ideal place for indirect HRT advertising, but they often contain misleading information. HRT can be bought online from Spain, without a medical consultation or prescription constituting a serious issue for public health. In our information society, it is the right and obligation of public health bodies to ensure that such information is not misleading. The balance between the benefits and risks of long term use of hormone replacement therapy (HRT) has been a matter of debate for decades. As early as 1939 the review published by Nancy Krieger in 2005 on the history and epidemiology of hormone replacement therapy (HRT) highlighted a potential association between HRT and breast cancer . HRT is Since 2004, the Spanish Agency for Medicine and Health Care Products, in consonance with the regulatory agencies in other countries, leading health care institutions and most scientific societies, has considered HRT to be potentially indicated only in the treatment of severe climacteric symptoms with a negative effect on quality of life. In this case, they concur that the minimum effective dose should be used for the shortest possible duration ,8.HRT is classified as a prescription-only drug in Europe. That is, a medical prescription is required, and therefore advertising is only permitted where it is aimed at professionals authorised to prescribe, and not at the general public . NeverthThe EU has indicted the need to review the rigour, integrity and consistency of health information published on the Internet . Spain aThe aim of the European Code of Good Practice in the Promotion of Medicines is to ensure that all pharmaceutical promotion methods, including the Internet, comply with current legislation . Other oIn order to analyse the phenomena of HRT internet advertising in Spain, this research has three main objectives:1. To estimate compliance with these regulations on the corporate web pages of the best-selling HRT drugs in Spain, in order to identify the degree of commitment of the corresponding pharmaceutical companies.2. To analyse references to the same drugs on non-corporate web pages, establishing the name and address of the registered company and possible sponsors, in order to identify potential connections or ties with pharmaceutical companies.3. To evaluate and quantify whether these prescription-only drugs are being sold on the Internet to the general public via online pharmacies based in Spain or abroad.In order to obtain the list of the best-selling and most frequently prescribed HRT brands in Spain, the Spanish Ministry of Health and Consumer Affairs General Directorate was consulted. These top eight products were Absorlent Plus, Activelle, Duofemme, Estalis, Estracomb, Merigest, Perifem and Progyluton.Using the drugs' commercial brands, a search was carried out in January 2009, simulating the kind of search strategy that a typical internet user interested in locating information about these drugs would employ, using the Google search engine (the most popular search engine amongst internet users) . All theThe corporate web sites were analysed for compliance with the following European Code's recommendations:1. Restriction of the information to a specialised public . Specifically, the obligation to register - supplying the professional body membership number - in order to access information aimed at health care professionals, was monitored.2. Obligatory inclusion of the drug's Summary of Product Characteristics.3. Conformity of the indications with the Patient Information Leaflet .4. Inclusion of the registered company name and address.5. Inclusion of complete bibliographic references, including references to the original source.http://www.whois.net (this website offers domain-based research services).Additionally, compliance with these same recommendations on non-corporate web pages referring to the same drugs was studied. If this information was not already explicitly stated on the page, the registered company name and address, and possible sponsorship, was identified using the website The following information was also collected on non-corporate web pages:- Whether the page offered links to sites selling medicines.- Erroneous or inadequate information concerning drug indications.The legal status of the online pharmacies was determined on the basis of the inclusion of the registered company name and address. In these cases, the availability of the drug's Summary of Product Characteristics, the stipulation of the need for a prescription and the presence of restrictions on access to the information, as well as the possibility of purchasing prescription-only medication from Spain was studied.Out of a total of 70 web pages  indicated HRT treatment for osteoporosis without mentioning a note of caution or the restrictions imposed by the Ministry for Health and Consumer Affairs due to the unfavourable risk-benefit profile % indicat. Five (1Two web pages (7%) providing medical information fulfilled the requirement of including bibliographic references and references to the original source. Results for providing different levels of information to patients and health professionals were mixed: 16 web pages made no distinction, five pages made no distinction but did insist on the need to consult a professional, five differentiated between patients and health professionals but did not restrict access to the information, and only one required the user to register in order to access the information, but did not require the user to prove their health professional status. Among the non-corporate web pages providing medical information, three included links to the sale of medications, although these did not include HRT drugs.http://www.goldpharma.com and http://www.rx-med.net) included had its base in Spain, although one was based in the European Union, specifically, the United Kingdom. None of them complied with the requirements analysed . In the case of these online pharmacies, medications could be purchased from Spain. Regarding legal status, Goldpharma  placed the onus probandi (burden of proof) on the user to check current legislation for each country and accepted no responsibility. Likewise, Rx-med  sells worldwide, but accepted no responsibility for compliance with legislation in other countries.None of the two online pharmacies (Despite important efforts by the European Union to regulate and control medicines, our study shows that the European Code of Good Practice for the Promotion of Medicines has not had the desired effect on the quality of the information available on the best selling pharmaceuticals in Spain.The corporate web pages of pharmaceutical companies owning HRT drugs do not comply with all the precepts laid down in this Code. On the other hand, forums and non-corporate web pages are promoting HRT irrespective of EU regulations. These websites contain misleading or erroneous information about the potential therapeutic uses of HRT, the information they provide is rarely based on scientific evidence, and they sometimes publicise online pharmacies. Similarly, the study confirmed a well-known fact that, despite EU prohibitions, it is still possible and easy to buy HRT medications from online pharmacies from anywhere in the world.For women seeking information about the benefits and risks associated with HRT, there is a wealth of information available, but this is frequently contradictory. Much of this information is found in the media. For example, the first item retrieved by our search on the web page of the Spanish Agency for Medicines was the 2002 warning , where tHRT has for decades been the source of a conflictive debate between pharmaceutical companies, epidemiologists, regulatory agencies and feminist groups. If a woman searches for HRT information online, the information she will find will be confusing, incomplete and frequently erroneous. In fact, women can even buy HRT online, without a prescription or medical advice and monitoring. This fact is particularly alarming since HRT drugs are powerful pharmacological agents shown to be thrombogenic and carcinogenic in the long term -4.Significant inappropriate HRT indications were observed in the advertising published on the web pages analysed, for example indicating the use of HRT to prevent osteoporosis whilst failing to mention the restrictions imposed on this particular use ,8. Of grControlling the promotion and sale of medicines through indirect online marketing presents a challenge to European regulatory bodies. Unaffected by any regulations in this respect, forums, chat rooms and non-corporate web pages all constitute an ideal place to promote medications indirectly, and to broaden the scope of drugs' therapeutic applications. Thus, faced with the impossibility of generating direct demand for prescription-only drugs in Europe, pharmaceutical marketing may exploit these "disease mongering" strategies for menopausal and postmenopausal women -21. OsteAt present, no specific body exists in Spain with the express remit of monitoring online sales of unauthorised medications. Due to the protection offered by the supranational structure of the Internet, countries possessing strict pharmaceutical controls have recently been overwhelmed with medications acquired in other countries with more permissive health legislations, and to date have been unable to prevent the phenomenon . HRT druSince the pharmaceutical companies have a vested interest in the quality and ethical and legal status of the information provided about their products, it was the industry itself which agreed to implement self-regulation regarding promotion. Thus, the pharmaceutical companies committed themselves to compliance with codes of good practices for the promotion of medicines ,14. HoweHealth information sites have proliferated, and in Spain there are now over 6,000 disease-related virtual forums . These wThe limitations of our study are related to the dynamic nature of the Internet, where content may vary each time a page is updated. Furthermore, it is possible that a search carried out at any time other than January 2009, could produce other web sites on the first results page. In addition, the selection of web sites did not comprise all the information and advertising available for each HRT drug analysed, as only the web sites appearing on the first results page were selected for analysis. Nevertheless, evidence suggests that users rarely look beyond the first results page .Beyond the interests of pharmaceutical companies for the quality advertising of their products, and particularly in the promotion and sale of these products on the Internet, it is, as Muir Gray states, the right and obligation of public health bodies in an information society to ensure that such information is not misleading in terms of health, disease and pharmaceutical therapies. To date, the health authorities have yet to make a serious move in this direction .Controlling the promotion and sale of medicines through indirect online marketing represents a challenge to European regulatory bodies. Even though pharmaceutical companies have committed themselves to compliance with codes of good practice for the promotion of medicines, deficiencies were observed regarding the identification, information and promotion of HRT medications on their web pages. Unaffected by legislation, non-corporate web pages are an ideal place for indirect HRT advertising often containing misleading information. HRT can be bought online from Spain, without a medical consultation or prescription constituting a serious public health issue.The authors declare that they have no competing interests.ECR conceived the study and participated in the design of the study, acquisition of data from the web pages, analysis of data and coordination and draft of the paper. MML participated in the design of the study, provided knowledge on the regulation of advertising and participated on the draft of manuscript. MTRC participated in the design of the study, acquisition of data from the web pages and helped to draft the manuscript. PAC participated in the design of the study and helped to draft the manuscript.All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/134/prepubAnnex 1. List of the web sites retrieved in the search of the best selling HRT pharmaceuticals in Spain.Click here for file


The Plant Journal for 18 yr. Her career tells us that she is a professional managing editor. I discovered this book when I was preparing The Editor's Academy, a three-day intensive training course for medical editors in Korea held in February 2008. The content of the book was a great source for the workshop. Furthermore, peer review, online submission, and misconduct in scientific research and publishing are interesting topics that recently has been of concerned to editors. The simple, lucid organization of this book includes the description of golden rules in the text and a summary in the appendix. This book consists of nine chapters: Introduction; Peer Review Process-How to Get Going; Manuscript Submission and Initial Check on Completeness and Suitability; Full Review Process; Decision Making Process for Reviewed Manuscripts; Moving to Online Submission and Review; Reviewers-A Precious Resource; Obligations and Responsibilities of the People Involved in Peer Review; and Misconduct in Scientific and Publishing-What it is and How to Deal with it.Ms. Irene Hames had served as managing editor of "Critical assessment of manuscripts submitted to journals by experts who are not part of the editorial staff." On the third page, the first golden rule appears: "Editors are responsible for ensuring the quality of their journals and that what is reported is ethical, accurate, and relevant to their readership." Throughout the book, boxes, bewares, and golden rules are frequently given to reinforce the messages of the text. The writing is fluent and warm, like a conversation with the reader, and is another reason why this book is strongly recommended to novice editors or editorial board members.In the introductory chapter, the author explained two factors that led to the spread of peer review. First, submissions to scientific journals are burgeoning. Second, editors are no longer experts in all areas of their specialties. The increase in submissions likely originated from increases in research funds and the use of publications to evaluate members of research institutes worldwide. The first page of the book includes a box highlighting the definition of peer review by the International Committee of Medical Editors: The content of chapters two to five concerns the review process and decision making, and the remaining chapters deal with online submission, routine work required of authors, and the reviewers' work. Chapter two presents a well-drawn flow chart of the submission and review process on page 10. In addition, the organization of the editorial office and the title and role of each member of the office are described (pages 12-13). Although not all editors/publishers can recruit an extensive office staff, especially when the journal is published by a non-profit scientific society, these titles and roles should be kept. If sufficient finances are available, full- or part-time editorial assistants should be considered to improve the editorial quality. In Korea, medical editors are usually very active clinicians or researchers who would quickly become exhausted without help from editorial assistants. Chapter four includes a checklist of the full review process (page 62). Ten items are explained to help the novice reviewer deal with a manuscript, such as scope, study objective, study design, and soundness of the results. Editors sometimes evaluate the quality of their reviewers, as is the case with the 'Review Quality Instruments' used by the British Medical Journal. Pages 80-81 Box 4.3 presents advice to the reviewer on how to prepare an ideal report for the authors and provides lucid guidelines for reviewers. In Chapter 5, Table 5.2 summarizes decision making after a review, including reviewer recommendations such as acceptable as stands, acceptable with minor revision, acceptable with major revision, reject with resubmission invited, and reject with no encouragement of resubmission (page 95). Another editorial task is to deal with authors' appeals. An editor should not be surprised when an author appeals, and automatic dismissal of appeals is not recommended. The editor should listen to the author and examine whether the reviewer made a mistake. Perhaps another reviewer can review the manuscript, or the editor can conclude that the manuscript is sound but explain how it falls outside the journal's scope.Chapter 6 addresses online submission in detail. Box 6.1 contains a useful checklist for selecting an online submission system (page 121). After implementing an online submission system, the number of submissions usually increases by around 25%, including an increased number of low-quality manuscripts, so it is important that the consistency of the review process is ensured."No conflict of interest or prejudice must be allowed to influence the submission of a manuscript, its review, or the decision on whether it should be published" (page 164). The existence of a conflict of interest does not mean that the manuscript is wrong or biased. The key is the disclosure of conflict of interest, so that the information can be used in the review process. This process increases the transparency of the peer-review process.The obligations and responsibilities of reviewers and editors are discussed in Chapter 8. One of the most important issues is conflicts of interest. Golden Rule 12 describes the principle lucidly: Science, to have cloned human embryos and harvested stem cells from them were found to be fraudulent. Plagiarism, duplicate publication, multiple submissions, digital image manipulation, authorship irregularities, and other issues are discussed. In addition, reviewer misconduct is addressed, such as failure to disclose a conflict of interest, disclosing confidential information, usurping authors' ideas, delaying reviews, or damaging the reputation of authors.The last chapter deals with misconduct in research and publication. This is still an ongoing issue, not only in Korea, but in scholarly society worldwide. Some examples of fabrication and falsification are presented, such as the cases of Jan Hendrik Schon, who fabricated or falsified data in at least 16 papers on the physical sciences, and Hwang Woo Suk, whose claims, published in Four appendices help to recall the full text: Golden Rules and the Peer Review Good-practice Checklist; Examples of Checklists, Guidance for Reviewers and Editorial Letters; Useful Websites; and Alternative Methods of Peer Review. All of this well-arranged information provides useful guidelines for practical editorial work. Many forms used by several famous journals are presented as a reference for editors.The text of this book includes material that editors deal with every day, and it helps to remind me of the editorial process. Editors should also be trained as researchers. Unfortunately, there is no well-organized training course in Korea. Only the Korean Association of Medical Journal Editors provides courses for editors. This wonderful work by Ms. Hames can be used as a textbook in courses for both experienced and novice editors, and I trust that it is what Ms. Hames intended when she prepared this beautiful book. Every scientific editor should read it.