Studies have shown that research participants fail to appreciate the difference between research and medical care, labeling such phenomenon as a "therapeutic misconception" (TM). Since research activity involving human participants is increasing in the Middle East, qualitative research investigating aspects of TM is warranted. Our objective was to assess for the existence of therapeutic misconception amongst Egyptians.Study Tool: We developed a semi-structured interview guide to elicit the knowledge, attitudes, and perspectives of Egyptians regarding medical research.Setting: We recruited individuals from the outpatient settings (public and private) at Ain Shams University in Cairo, Egypt.Analysis: Interviews were taped, transcribed, and translated. We analyzed the content of the transcribed text to identify the presence of a TM, defined in one of two ways: TM1 = inaccurate beliefs about how individualized care can be compromised by the procedures in the research and TM2 = inaccurate appraisal of benefit obtained from the research study.1) and a smaller number of participants (5/15) manifested an unreasonable belief in the likelihood of benefits to be obtained from a research study (TM2). A total of 12 of the 15 participants were judged to have expressed a TM on either one of these bases.Our findings showed that a majority of participants (11/15) expressed inaccurate beliefs regarding the degree with which individualized care will be maintained in the research setting (TMThe presence of TM is not uncommon amongst Egyptian individuals. We recommend further qualitative studies investigating aspects of TM involving a larger sample size distinguished by different types of illnesses and socio-economic variables, as well as those who have and have not participated in clinical research. For more than two decades, commentators have expressed concerns about research participants not distinguishing between research and clinical care -3. Indee1); or 2) when research participants hold an unreasonable appraisal of the nature or likelihood of medical benefit from their study participation (TM2) .Participant: "How so?"Interviewer: "I'd prefer to take the old drug of course"Participant: The following are examples of responses indicating participants' unreasonable appraisals of the magnitude and likelihood of benefit that one obtains from participating in a research study:"If the study will have a negative impact on me, I won't participate. It must have some guidelines that guarantee that it will protect me, so that I'll agree to participate". Later in the same transcript:Participant: "It's like I said, you usually won't resort to entering a study or a [clinical] trial unless you feel like there's something that you may gain from being in it".Participant: "Would you agree to participate in a medical research study?"Interviewer: "Certainly these studies won't have side effects, the goal is to improve health and not cause harm".Participant: Would you allow one of your children to be in a research study?Interviewer: "I must be at least 90% reassured that it's something safe."Participant: "Essentially, participants believed that there was good assurance that clinical research was associated with benefits or that there would be no or relatively low risks, thus calling into question participants' understanding of the risk/benefit ratio associated with such studies.1). A smaller number also had a misconception of what is achievable in terms of benefits from the nature of the clinical trial (TM2). According to Appelbaum and colleagues, TM occurs "when a research subject fails to appreciate the distinction between the imperatives of clinical research and of ordinary treatment, and therefore inaccurately attributes therapeutic intent to research procedures" [The majority of the participants in this study manifested a misconception regarding how their personal care in medical research might be compromised by the procedures of the study TM. A smallcedures" .Commentators have hypothesized several conceptual foundations for the presence of TM. First, potential participants might harbor a misunderstanding of how clinical research and patient care differ in their purpose, characteristic methods, and justification of risks . In addiAlternatively, many aspects of research participation might be construed as clinical activities and therefore, participants might see research as just another way of providing care for them . For exaOur study, being exploratory in nature, used a semi-structured interview technique that involved both patients and members of the lay public and relied on presenting hypothetical clinical research scenarios to these participants. Other empirical studies have used a variety of approaches to assess for the presence of TM. For example, studies have explored this phenomenon in patients who have participated in clinical trials -7,21 or We believe that qualitative research design methods are preferred when exploring the presence of and the explanations that can account for TM. Such studies can perform a more extensive probing into the reasons for the participants' TM. For example, qualitative studies can explore for how patients view care in the research setting, their feelings about the researchers juxtaposed upon those for their primary physicians, and for the presence and type of trust they place in researchers compared with their physicians. Also, commentators have claimed that a concept of therapeutic misconception should be distinguished from that of therapeutic misestimation, which occurs when participants understand the distinction between research and clinical care, but their skewed estimates of risks and benefits result other reasons, such as a misinterpretation of probability information ,22. QuanSeveral studies have investigated the existence of participant- or study-related factors associated with the presence of TM through multivariate analysis ,6,7. In There are two major ethical concerns with the TM. First, failure to appreciate correctly the risks and benefits of research participation raises concerns regarding the validity of informed consent ,4,23. InWe recognize several limitations of our study. First, the extent with which our findings are applicable to other populations in Egypt or other countries in the Middle East is constrained by the small sample size and the selection bias associated with obtaining information from only those who agreed to participate in this interview study. Second, the education level of our participants was higher than the median level of Egyptians from other parts of the country, thus questioning the applicability of our results to other regions in Egypt. However, Appelbaum and colleagues  showed t1), as well as a misconception of what is achievable in terms of benefits from the nature of the clinical trial (TM2). We recommend further qualitative studies (both focus group discussions and in-depth interviews) investigating aspects of TM involving a larger sample size consisting of participants with different illnesses and socio-economic variables, as well as those who have and have not participated in clinical research.In conclusion, the presence of TM is not uncommon amongst Egyptian individuals. Participants held a misconception regarding how their personal care in medical research might be compromised by the procedures of the study (TMThe authors declare that they have no competing interests.MW made substantial intellectual contributions to this study, was involved in the conception and design of the study, analyzed the data, and wrote drafts of findings. SSK made substantial intellectual contributions to this study, was involved in the conception and design of the study, collected the data and helped with the analysis of the data. HJS served as senior author, conceived the project, supervised data collection process, analyzed the data, and reviewed and edited draft manuscripts. All authors read and approved the final manuscriptMW is Associate Professor in the Department of Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, The University of Jordan, Amman, Jordan. SK is a resident in Obstetrics and Gynecology at Staten Island University Hospital, Staten Island, New York. She received her medical degree from Ain Shams University, Cairo, Egypt. HS is Professor of Medicine at the University of Maryland, School of Medicine, Baltimore, Maryland. He is the Principal Investigator of a Bioethics Career Development Training Grant from the Fogarty International Center, National Institutes of Health.The pre-publication history for this paper can be accessed here:


Recent advances in GIS technology and remote sensing have provided new opportunities to collect ecologic data on agricultural pesticide exposure. Many pesticide studies have used historical or records-based data on crops and their associated pesticide applications to estimate exposure by measuring residential proximity to agricultural fields. Very few of these studies collected environmental and biological samples from study participants. One of the reasons for this is the cost of identifying participants who reside near study fields and analyzing samples obtained from them. In this paper, we present a cost-effective, GIS-based method for crop field selection and household recruitment in a prospective pesticide exposure study in a remote location. For the most part, our multi-phased approach was carried out in a research facility, but involved two brief episodes of fieldwork for ground truthing purposes. This method was developed for a larger study designed to examine the validity of indirect pesticide exposure estimates by comparing measured exposures in household dust, water and urine with records-based estimates that use crop location, residential proximity and pesticide application data. The study focused on the pesticide atrazine, a broadleaf herbicide used in corn production and one of the most widely-used pesticides in the U.S.We successfully used a combination of remotely-sensed data, GIS-based methods and fieldwork to select study fields and recruit participants in Illinois, a state with high corn production and heavy atrazine use. Our several-step process consisted of the identification of potential study fields and residential areas using aerial photography; verification of crop patterns and land use via site visits; development of a GIS-based algorithm to define recruitment areas around crop fields; acquisition of geocoded household-level data within each recruitment area from a commercial vendor; and confirmation of final participant household locations via ground truthing. The use of these procedures resulted in a sufficient sample of participants from 14 recruitment areas in seven Illinois counties.One of the challenges in pesticide research is the identification and recruitment of study participants, which is time consuming and costly, especially when the study site is in a remote location. We have demonstrated how GIS-based processes can be used to recruit participants, increase efficiency and enhance accuracy. The method that we used ultimately made it possible to collect biological samples from a specific demographic group within strictly defined exposure areas, with little advance knowledge of the location or population. The U.S. Environmental Protection Agency has defined pesticides as substances that are intended to prevent, destroy, repel or mitigate pests. Pests include insects, animals, weeds, fungi and microorganisms such as bacteria and viruses . AlthougAnimal bioassays have shown many pesticides to be carcinogenic and some are known or suspected human carcinogens. Agricultural Health Study results have indicated that prostate and ovarian cancer incidence rates are elevated for male and female pesticide applicators, respectively . PesticiA number of studies have used GIS and remote sensing technologies to aid in agricultural pesticide exposure research. Many of these incorporated spatial functions such as distance measurement, buffering, and overlay analysis. Most used historical data on crops and their associated pesticide applications and measured residential proximity to agricultural fields.Schreinemachers  used couDue to time and financial constraints, or an historical timeframe, very few of these studies collected environmental and/or biological samples from household members. The challenges faced by researchers in the analysis of household samples include: 1) identification and recruitment of study participants, 2) estimation of exposure and/or verification of pesticide use, and 3) accurate measurements of distance between study homes and pesticide application sites. Many pesticide study populations are drawn from disease registries or health outcomes databases, such as: state cancer registries ,23,28, bThere are some exceptions, however. For their study of organophosphate metabolite concentration, Royster et al.  recruiteThe identification of study fields and recruitment of study participants is a complex process that is often glossed over in reports of pesticide research. In this paper, we present a cost-effective, GIS-based method for crop field selection and household recruitment in a prospective pesticide exposure study. For the most part, our multi-phased approach was carried out in a research facility, but involved two brief episodes of fieldwork for ground truthing purposes. The method presented here is part of a larger study designed to examine the validity of indirect pesticide exposure estimates by comparing measured exposures in household dust, water and urine with records-based estimates that use crop location, residential proximity and pesticide application data. The timing of field identification, household recruitment and collection of biological samples was critical to our study, due to the half-life of atrazine, which is about 60 days in topsoil.The use of GIS was central to the process of household recruitment. In the initial stages, we used it for the identification of potential study fields, the spatial definition of household recruitment areas, and mapping of study households. In later stages (not reported here), we used it for distance and directional measurements. The methods that we used to recruit household members ultimately made it possible to collect biological samples from a specific demographic group within strictly defined exposure areas, with little advance knowledge of the location or population.Our study focused on the pesticide atrazine, a broadleaf herbicide used in corn production and one of the most widely-used pesticides in the U.S. We chose Illinois as our study state because of its high corn production and heavy atrazine use Table . In 2002For inclusion in the study, a field had to be: 1) planted in corn during the spring of 2003, as biological and environmental samples would be collected after atrazine applications; 2) at least 1000 meters away from a "conflict field," i.e. any other field planted in corn that could also be treated with atrazine, thus potentially making determination of exposure source problematic, and 3) within 200 meters of a moderately populated residential area. Our study team used aerial photographs from the Illinois Natural Resources Geospatial Data Clearinghouse  to visuaOur preliminary review indicated that the best field candidates would be on the edge of medium to large towns, thus allowing for an appropriate housing density moving away from the field's edge. From these photographs, we identified 95 potential fields from 17 counties. Given the large number of cornfields in Illinois, one might ask why our examination included so many counties. The reason is that cornfields are so ubiquitous that it was very difficult to find "isolated" fields, i.e. fields far enough away from conflicting fields.For each of the 95 potential fields, we digitized the field boundary closest to target households using Environmental Systems Research Institute's (ESRI) ArcGIS software. We then created buffers at distances of 200, 500, 800, and 1,000 meters from the edge of the field. These buffers were based upon studies of pesticide spray drift [e.g. ] and serWithout ground truthing, there was no way to determine which crops were being grown in each field. Field selection was reliant on aerial photography taken in 1998 and 1999 because processed, up-to-date satellite imagery was not available for our large study area and our project budget did not include funds for image processing. Additionally, many of the areas identified for possible study were on the edges of towns experiencing population growth and new housing development. Because such construction could completely change the study area as it had been defined, or remove the selection of a field as a candidate altogether, it was impossible for the study team to predict which fields would actually be eligible for the study without traveling to Illinois to confirm crop patterns and current land use.We conducted fieldwork in fall 2002 and spring 2003. The purpose of the 2002 visits was to verify crop and land use patterns and eliminate fields that were not candidates. This would provide us with adequate planning time to recruit study participants prior to the spring 2003 planting. Due to the fact that corn and soybeans are typically rotated annually as a "best management practice" for better crop yields ,34, we sIn order to facilitate visits to all of the potential candidate fields we reduced the number of candidate fields to 80 and split them into two groups of 40 to enable separate field trips covering different areas of the state. We used paper maps of each field, similar to the version shown in Figure At the end of the two initial field trips, 34 potential fields in 10 counties remained in the study. Those removed from consideration either had corn residue on the fields at the time of observation, suggesting that soybeans would be the crop for the following year, or the location was no longer a crop field.The next step was to identify households eligible for participant recruitment. Based on information from the fall 2002 site visits, boundaries for some fields were redrawn and new buffers created. Our goal was to develop an appropriate sample size of children living within each of the buffer zones . This required the following information: 1) household composition – occupants' ages, type of dwelling ; 2) household location, i.e. latitude and longitude; and 3) contact information – address and phone number. After contacting marketing list vendors, we chose a vendor that provided information about all households fitting the study requirements that were within a specified radius from any known address that we provided. This method was determined to be the most cost-effective, as we could locate an address at the center of the study area and then create a radius to incorporate all the homes within the study buffers. Because fees were based on the number of addresses provided by the vendor, one of our challenges was to develop a method to capture all of the homes within the study areas while eliminating areas that did not meet our requirements, thus keeping costs down.To achieve this, we developed an algorithm that we applied to all study fields. We located the centroid of the 1,000 m field buffer, as well as the half-way point along the field boundary (arc) closest to the study area. A straight line was drawn between these two points, running from the field boundary to the edge of the 1,000 m buffer. The center point of this line was designated as the center point of the study area Figure .Next, we had to find a real address as close as possible to this center point. This was a multi-step process. First we overlaid TIGER 2000 streets on the study area and identified the road closest to the center point. Using the address range along the road segment as a guide, we selected a fictitious address on the street and found a corresponding ZIP+4 for the address on the U.S. Postal Service web site . When thFinally, we determined the size of the radius needed to capture all potential candidate households in the study area by buffering the central address in increments of one-tenth of a mile (a requirement set by the vendor) until all of the homes in the study area were contained within the radius. On completion, we provided the central address and radius length to the data vendor.The vendor provided geographic coordinates and other data about all homes in the specified study area. Using these data we identified all single-family homes with at least one child aged 4 or younger. For each study field, we created a GIS layer consisting of homes that met the study criteria and overlaid this with the aerial photography, buffer zones, and conflict fields. From this procedure we were able to determine the approximate number of potential candidate households in the area, as well as how these households were dispersed across the four buffer zones. In accordance with our study design, we determined that the optimum number of participating households in a study area was six, with two in each of the 0 to 200 m and 800 to 1000 m buffers, and one household in each of the other two buffers. From this initial overlay, it was possible to determine whether any of the fields were unacceptable due to a lack of potential household participants or because of inconsistently-spaced households throughout the study area. Some homes were also excluded because of their proximity to conflict fields. At the end of this process, 24 candidate fields remained, located between Rockford and East St. Louis, Illinois.In late spring 2003, we made two field trips to Illinois with the primary goal of verifying that corn was being grown in the candidate fields (and not in any conflict fields). We also needed to ascertain that the geocoded homes of potential recruitment households were located accurately. Mapping the residential location of study participants is an important component of pesticide exposure studies, as it allows researchers to measure distance and direction from agricultural fields. In most cases, address geocoding, which interpolates where an address falls along a street centerline, is used to assign geographic coordinates to residences. Much has been written about the accuracy of geocoding methods for epidemiologic studies -38. WhenGoogle Earth was launched in October 2004, too late for use in our study. For record-keeping and editing, we used ESRI's ArcPad software on a handheld computer with a GPS unit attached. Our application contained aerial photography and map layers of house locations, field boundaries, buffers, and conflict fields. Figure Using address lists of all housesholds that met our study criteria, we navigated to each household and compared the geocoded point to the actual house location. Many of the geocoded points were inaccurate. To resolve this, we edited the shapefile using ArcPad and moved each point to its corresponding rooftop on the aerial photograph. Making edits in the field reduced the chance of inaccuracies during data transfer from paper to digital formats. In several cases, we discovered that the correct location of the house put it into a different buffer zone or even outside the study area. The inaccuracy of the original geocoded houses confirmed that the fieldwork verification process was integral to the accuracy of the study's final results. During this process we visited and verified the locations of 304 houses. At the conclusion of this stage of the investigation 21 fields remained viable for the study.Figure Household recruitment and sample collection procedures are being reported elsewhere, however, we ultimately enrolled 58 participants from 14 study fields in seven Illinois counties. Field locations are shown in Figure In recent years, there has been a proliferation of epidemiologic research that utilizes GIS and spatial analysis. One of the greatest challenges of these studies is the accurate assessment of exposure. Too often, proximity is used as a surrogate for exposure, without reliable information to back up its use. The two main objectives of our larger research have been to 1) determine whether there is a clear exposure gradient with distance from corn fields and 2) evaluate the correspondence between predicted vs. actual exposures by comparing record-based methods with biological and environmental samples. The results of our larger study are being reported elsewhere, but the initial first steps of identifying study fields and participant recruitment areas have been reported here.We successfully implemented several procedures designed to meet the requirements of locating candidate fields and homes. Through aerial photograph interpretation, we were able to identify potential fields and recruitment areas; however, ground truthing was necessary to confirm these selections. Without fieldwork, this portion of the investigation would have been impossible. Once in the field, the utilization of digital technologies with ArcPad aided in data collection and increased accuracy of field delineation and household location.Using geocoded points provided by marketing list vendors was integral to the success of our task. However, geocoding as a means for precise address location is not infallible. Without ground truthing the geocoded results, we would have been unable to accurately locate homes that possessed the desired demographic characteristics in relation to candidate fields, which would have significantly compromised the project.Fieldwork always has its challenges and, in this case, timing was critical since it relied on the planting and harvest cycles of crops. We did not anticipate the loss of so many potential candidate fields to surburban housing development. Despite these challenges, we were able to accurately and efficiently place homes within the study area and locate those that met the criteria imposed by the project. None of this would have been possible without the use of GIS and digital spatial technologies.We have presented a novel approach to the complex process of selecting study fields and identifying households for the recruitment of study participants. However, in the past two-three years, new technologies and data products have become available that could have enhanced our multi-step process. In October 2004, Google Earth was launched. With up-to-date aerial photography, the use of Google Earth may have precluded the need to ground truth geocoded addresses.In 1996, the U.S. Department of Agriculture (USDA) implemented the Cropland Data Layer (CDL) program . Each yeIn order to evaluate the accuracy of Cropland Data Layer corn and soybean classifications for our study, we conducted a retrospective analysis using DOQs of 46 fields, on which we had identified and marked crop types during our 2002 and 2003 field visits. Of these 26 (57%) were classified correctly and 4 fields (9%) were covered by clouds. In general, accuracy was greater for larger fields. The two most common misclassifications were: 1) soy or corn was classified as pasture/grassland and 2) soy and corn pixels were interspersed. Given the rate of accuracy and the small size of some of our study fields, ground truthing would have been necessary to our study even if the satellite imagery data had been available in a more timely manner.An important aspect of our study design was the premise of crop rotation as a means of predicting the following year's crop. Table While the Cropland Data Layer focuses on cropland, it also contains information about other landuses, including urbanization. Between the years 1999–2003, Illinois lost an average of 4–5% of its corn/soy acreage annually to urbanization, much of it in the form of new housing. We certainly noted this trend during fieldwork and lost many potential study fields to it.We have demonstrated how GIS-based processes can be used to recruit participants, increase efficiency and enhance accuracy, resulting in the collection of biological samples from a specific demographic group within strictly defined exposure areas, with little advance knowledge of the location or population. In addition to being cost-effective, our iterative, multi-pronged method provided us with the quality control needed for our study. If we had not used this methodology, we would have comprised quality and accuracy. Inaccurate geocoding would have placed some potential study houses in the wrong buffer and invalidated our sampling strategy. Without field checks, time would have been wasted in geocoding homes in invalid study fields, such as those that were not planted in corn or had disappeared due to suburban development. While our methodology may require refinement, in light of new data and technologies, it provides a valuable framework for study field identification and household recruitment.The authors declare that they have no competing interests.All authors are responsible for the project design. JLEA and RJC carried out most of the GIS analysis. JLEA, RJC, CLH and MJP conducted the fieldwork. JLEA and CLH wrote the bulk of the manuscript, with contributions from the other authors. TCW was the project PI. All authors read and approved the final manuscript.


A multi-domain suite of instruments has been developed by the interRAI research collaborative to support assessment and care planning in mental health, aged care and disability services. Each assessment instrument comprises items common to other instruments and specialized items exclusive to that instrument. This study examined the reliability of the items from five instruments supporting home care, long term care, mental health, palliative care and post-acute care.Paired assessments on 783 individuals across 12 nations were completed within 72 hours of each other by trained assessors who were blinded to the others' assessment. Reliability was tested using weighted kappa coefficients.The overall kappa mean value for 161 items which are common to 2 or more instruments was 0.75. The kappa mean value for specialized items varied among instruments from 0.63 to 0.73. Over 60% of items scored greater than 0.70.The vast majority of items exceeded standard cut-offs for acceptable reliability, with only modest variation among instruments. The overall performance of these instruments showed that the interRAI suite has substantial reliability according to conventional cut-offs for interpreting the kappa statistic. The results indicate that interRAI items retain reliability when used across care settings, paving the way for cross domain application of the instruments as part of an integrated health information system. Population aging and the increased burden of disability in middle and high income nations pose unique challenges to health care systems. The lives of frail elderly individuals and persons with disability are affected by complex interactions of physical, social, medical and environmental factors that necessitate multidisciplinary approaches to care. Services tend to be provided by a variety of health and social service agencies including both community and facility-based settings. For example, persons who are experiencing cognitive loss or decline of functional ability may receive support from home care agencies, supportive housing, rehabilitation services, or nursing homes. Similarly, persons with mental health problems may receive psychiatric services in primary care, community mental health programs, mental health group homes, or in-patient psychiatric units of hospitals. At the end of life, palliative care may be provided by community-based agencies or by residential hospices, but periodic contact with acute hospitals is also not uncommon. For each of these populations, health and social services are intended to be provided through an integrated system of care rather than through a singular organization.The need to receive support from multiple service agencies has important implications for persons with complex care needs. At the individual level, there may be a risk of discontinuity of care if information systems are not compatible or if clinically relevant information is not shared between agencies. This may mean that needs are not identified when tra was designed to be used with a variety of vulnerable populations [The interRAI family of assessment instruments ulations ,3. The fulations . The intulations . By 1996ulations . The RAIulations  was the ulations ,12, RAI-ulations , and RAIulations .The development of all these assessment instruments was guided by the design principles for the original RAI. The assessments were intended to use all sources of information available. Judgments were to be based on observable traits, have operational definitions and coding instructions that specified inclusion and exclusion criteria, and use clearly delimited time frames for observations anchored to a specific assessment reference date. In addition, each of these instruments was intended to support applications for multiple audiences including care planning, outcome measurement, quality improvement, and resource allocation. To this end, efforts were made to retain the capacity to derive or extend existing outcome measures  and decision support algorithms .The initial set of RAI instruments was developed in a serial process. For new instruments, this meant that lessons learned from the use of earlier instruments were taken into account in the development of subsequent instruments. However, the need to refine older instruments became apparent as innovations were identified. Also, it was recognized that the family of instruments should be refined in parallel, treating the collective set of instruments as an integrated system rather than as complementary, but independent assessments for specialized care settings.In the year 2000, interRAI launched a multinational effort to update the entire family of RAI instruments and to develop new instruments for sectors not yet addressed by the existing instruments. The result of this effort is an integrated suite of instruments providing compatible assessment approaches for nursing homes, home care, acute care, post acute care, palliative care, assisted living, supportive housing, services for persons with intellectual disabilities, community mental health, emergency psychiatry, and inpatient psychiatry. The initial focus of the redevelopment effort for the interRAI suite of assessment instruments was to identify a common core set of about 70 items that would be present in all instruments, with exceptions permitted only for specialized settings where prevalence rates for the item will be negligible . Examples include items such as cognitive skills for decision making, activities of daily living , mood , behaviour problems , falls, and health symptoms . The next step was to identify over 100 optional items that would appear in many, but not all, instruments. These items were expected to be relevant to several service settings, but not pervasive enough in all service settings to warrant inclusion in the list of core items. Examples include long-term memory, situational memory, hearing aid use, family/close friends feeling overwhelmed by the person's illness, instrumental activities of daily living , stamina, additional health conditions , medication adherence, and preventive interventions and screening . Finally, specialized items that would only appear in specific instruments were also identified. For example, the in-patient psychiatry instrument has 170 unique measures  whose prevalences would be too low to warrant their use in non-mental health settings.Once the initial item set was identified for the interRAI instruments, a 12-country effort was launched to evaluate the psychometric properties of the instruments in different health care settings. The present paper reports on the results of that cross-national effort with a particular emphasis on inter-rater reliability. There have been several studies of the reliability and validity of the early versions of interRAI instruments for nursing homes -20, homeinterRAI Fellows from 12 countries  volunteered to test one or more of five instruments available by 2005 for long-term care facilities, home care, palliative care, post-acute care, and mental health. Individual researchers selected instruments based on the availability of pilot sites in their countries, which was often dependent on patterns of use of the earlier versions of the instruments. For each instrument, interRAI created a detailed item by item instruction manual, with item definitions, process instructions, and examples. Field staff members were trained to do the assessments following this instructional set. These trained clinicians then completed dual assessments for 783 individuals. As shown in Table The five assessment instruments used in this study were the interRAI Long Term Care Facility (interRAI LTCF), interRAI Home Care (interRAI HC), interRAI Post Acute Care (interRAI PAC), interRAI Palliative Care (interRAI PC), and interRAI Mental Health (interRAI MH). All items are coded using the same assessment approach; namely, the assessor uses all sources of information and then exercises clinical judgement as to the most appropriate answer based on standardized coding guidelines provided in the instrument's training manual. Most items permit the use of multiple information sources including personal interviews, review of the chart, direct observation of the person, communication with informal caregivers, and use of clinical communication between health care staff . However, a limited number of items are restricted to recording only the person's self report . All items include standardized responses sets with item definitions, inclusions/exclusions, and observational time frames provided in the manual and on the assessment form. As noted earlier, all assessments include a set of common core data elements, which are the primary focus the present analyses, as well as specialized items unique to that service setting. The items typically are rated based on the presence or absence of a condition, frequency of its occurrence in a standardized time frame , or severity based on anchor terms defined in the assessment manual . The number of common and unique items for each instrument examined in the present study are reported in Table In each participating site, two health professionals completed their assessment of the same individual independently at different times. Assessors were blinded to others' results and they were not permitted to discuss the case with each other, nor were they permitted to exchange information; however, they were both able to access the persons chart when completing their assessment. The intent of this approach was to use a conservative methodology for evaluating inter-rater reliability in a manner that would mimic real-world assessment experiences. This methodology provides a more realistic appraisal of inter-rater reliability than would be obtained from use of artificial case examples or simultaneously completed assessments.It was not the purpose of the study to make comparisons between sites or countries. Therefore, the protocol did not call for selection of randomized samples, and there was no requirement for countries to target common populations or settings. In order to reduce burden on staff and to simplify the approach for obtaining consent, convenience samples were used, but study coordinators were encouraged to obtain data for heterogeneous samples in order to test the applicability of the instruments in diverse clinical populations.The study protocol required dual assessments to be done within 72 hours, but staff were encouraged to complete them in less time particularly in settings with a higher risk of rapid rate of clinical change . The actual number of hours between assessments was not recorded electronically, so it is not possible to estimate the average time between assessments.Assessors were trained to use a variety of information sources, such as direct observation, interviews with the person under care, family, friends, or formal service providers, and review clinical records, both medical and nursing. The assessors were ordinary clinical staff, external research staff, or a mixture of both. Most assessors were nurses, but other professionals were also used. In line with interRAI's standard approach to coding, they were all instructed to exercise their best clinical judgment in order to record observations based on their evaluation of the most accurate information source.All assessments were recorded in paper form and either entered locally into a database or sent to the project team for transcribing and analysis. Data from all countries were then combined into a single analytic data set for the cross national analyses.Assessors were asked to track the time used to complete the assessment and to fill out a debriefing form on their experience in doing the assessment. This information was used by local project coordinators in participating countries to monitor how close the instruments were to meeting the target completion time and to collect comments that could be useful in future discussions regarding the refinement of the instruments. However, since the forms were considered an optional part of the protocol, this information was not always forwarded to the project coordinators and these data were not compiled electronically for further analysis. That said, there were no international reports of major problems with the study protocol or draft versions of instruments reported to the study team.The reliability of the various interRAI instruments was evaluated mainly with weighted kappa coefficients using Fleiss-Cohen weights . For binKappa values are generally preferred as indicator of reliability over percentage agreement, because the latter may under-represent the reliability of multi-level items with modest disagreements regarding severity of a given problem. Percentage agreement will also over-represent reliability for binary items with highly skewed distributions.Ethical considerations were addressed by the appropriate research ethics committee in each country providing data in accordance with national guidelines.Table Figure The number of specialized items that were unique to individual instruments varied from as few as 8 items in the PAC to as many as 170 items in the MH. Considering these specialized items, the PAC showed the highest mean kappa value (0.73), while the other instruments varied between 0.63 and 0.68  CARE project). However, the interRAI suite of instruments differ from these tools in several important ways: a) applicability to a much broader range of service settings; b) use of a common core set of items linking all instruments combined with instrument-specific specialized items that are unique to the special needs of the populations served within specific care settings; and c) all instruments in the suite support multiple clinical and management applications for multiple audiences, including care planning, case mix classification, outcome measurement, quality management, and patient safety assessment.The present results on reliability are compelling. Virtually all of the items tested met or exceeded standard cut-offs for acceptable reliability and a substantial proportion of items showed excellent reliability. This is particularly important given that a relatively conservative study protocol was used for completion of the assessments in order to provide a parallel approach to real-world assessment practices. These results demonstrate that motivated, appropriately trained staff can obtain high quality assessment results as part of normal clinical practice, and the domain areas assessed in the interRAI instruments can be assessed effectively in multiple settings serving persons of different ages with different strengths, preferences, and needs.The development of any new assessment requires a substantial commitment of time and resources. The development of the new interRAI suite occurred over a five-year period of intensive research involving multidisciplinary teams of researchers based in 12 countries. An important consideration in international dissemination is translation and evaluation of cross-cultural applicability. Hence, it is important to establish not only the psychometric properties of assessment instruments in a single language. The present study demonstrates that the interRAI instruments are reliable in multiple languages and multiple countries. In addition, the interRAI development effort relies on extensive feedback from clinicians to ensure cultural appropriateness, clinical relevance and applicability of assessment items. The strategy of using all sources of information available to the assessor and the use of standardized coding rules and item definitions for interpretation by assessors provides the appropriate level of flexibility needed to ask questions in a cultural relevant manner while at the same time ensure international data standards. This is demonstrated in the present study by the high reliabilities achieved in North American, European, Asian, and Australian samples. interRAI is currently in the midst of ongoing translation (and back translation) of its entire suite of instruments into all of the languages represented in this, at present, 29-country network.It was not surprising to note some modest cross-sector differences in reliability for the different interRAI instruments. While every instrument achieved high reliabilities overall and at the item level, the interRAI HC and interRAI PC obtained somewhat lower reliabilities than the other instruments in this study. Only about 15 percent of the items in the LTCF, PAC, and MH instruments had kappas below 0.60, whereas the HC and PC had about 25 percent of items below this value. There are a number of explanations for these findings. In the case of palliative care clients, the rate of clinical change and the fluctuations of symptoms and function at the end of life would be an important consideration for any protocol requiring repeat assessments at different time points. In the home care environment, staff members are more reliant on other, non-clinical informants  to report on their observations over the previous three days. In facility settings, like nursing homes, psychiatric hospitals/units, or post-acute care, staff members are available on a 24-hour basis and use daily charting systems to monitor the person's status. Similarly, these facilities are more likely to have service utilization records  readily available in the chart accessible to staff at the time of the assessment, whereas home care case managers may need to rely on family members for this information. Therefore, it is not surprising to see a somewhat higher level of reliability in facility-based care settings.and over time as the person returns to living in the community.The capacity to obtain reliable, compatible, clinically relevant data from multiple service settings has important implications for integrated systems of care. For example, if a person in one service setting has been assessed immediately prior to a transition to another setting  staff may use the assessment performed in the prior service setting as baseline information to use in transitional care planning. The ability to utilize assessments done in other sectors should result in a net reduction of assessment burden in the overall system since the basis for reassessment should become significant clinical change rather than mistrust of data obtained from other health professionals. In addition, the earlier assessment provides baseline information that may be used to track clinical outcomes during the transition period . At the organizational level, the ability to link data from multiple service settings provides the opportunity to examine quality of care from the system-level rather than the organization level alone. For example, by linking interRAI MH discharge data with subsequent interRAI Community Mental Health data one would have the opportunity to benchmark mental health quality indicators related to clinical outcomes over the inpatient episode While the present study yielded encouraging results related to reliability, there is considerable additional research underway related to the new interRAI suite of instruments. For example, the validity of items and scales in these instruments will be reported in future publications. The 12-country study described here included the additional simultaneous measurement of several other well-known scales . These data will be used to evaluate the concurrent validity of existing interRAI scales  for psychiatric conditions. Hence, the new suite of interRAI instruments can be considered to be an important step forward in achieving international standards for assessment of vulnerable populations with complex care and support needs.The inter-rater reliability results from the early use of the new suite of interRAI instruments shows that most of the items in these instruments work very well in multiple service settings. This means that clinicians, administrators, policy makers, and researchers can have considerable confidence in the data obtained for different populations receiving services in different sectors of the health care system.The opportunities for cross-sector and cross-national comparisons based on the interRAI instruments hold considerable promise for developing effective strategies for responding to major global challenges related to population aging and the expansion of disability. Having established a common metric to measure major questions of interest to service providers, planners, and policy makers, the capacity to use evidence to inform decision making at all levels of the health care system has increased greatly.The authors declare that they have no competing interests.JPH and GL jointly drafted the first version of the manuscript. JNM provided oversight to the international data collection, dataset preparation, and analysis for this manuscript. JPH, DF and other interRAI Fellows mentioned in the acknowledgements managed data collection in their respective countries. All other co-authors contributed toward conceptualization and revision of the manuscript, and they approved the final version.The pre-publication history for this paper can be accessed here:


Incidence of farmers ending their lives in Vidarbha region had hit epidemic proportions recently. We adopted the psychological autopsy approach to offer some insight into the reason why these individuals resorted to such a drastic step. Suicide in farmers is public health problem and we suggested some immediate and serious interventions to prevent suicide. After the independence, according to Gandhiji's vision of Gram-Swaraj, villages and specially farmers were to be the main focus of any development plan of India. As years passed, by agriculture as an industry lost its importance for policy makers of India. This over the time caused severe distress among the farmers leading to recent dramatic rise in the number of suicides among farmer community. Every day in national newspaper invariably there is news related to farmers' suicides.India consisting of 16% of world's population sustains only on 2.4% of land resource. Agriculture sector is the only livelihood to the two-third of its population which gives employment to the 57% of work force and is a raw material source to large number of industries. Despite of portrayal of farming as a healthy and happy way of life, agriculture sector experiences one of the highest number of suicides than any other industry. Farmers' suicide is not only reported in Vidarbha region of Maharashtra, but also from Punjab, Uttar Pradesh, Kerala, and Karnataka. Many enquiry commissions were formed and recommendations were implemented especially in Punjab.[In 1990s, India woke-up to a spate of suicide among farmers community. The first state where suicides were reported was Maharashtra with particular reference to Vidarbha region. A look at the figures given out by State Crime Records Bureau makes it evident that farmers as a professional category is suffering from this problem of high-suicide rates. Approximately 3.4 million cotton farmers occupy the Vidarbha region  and 95% of them struggle with massive debt, according to the Vidarbha Jan Aandolan Samiti .[We have studied the status of farmers' suicide in Vidarbha region on the request of Wardha district administration. We adopted the psychological autopsy approach to offer some insight into the reason why these individuals resorted to such a drastic step.In India, however, problems in identifying the population base and in the certification of death has meant that the true magnitude of the problem is yet to be realized.Several studies undertaken in India have revealed the incidence of suicides to vary from 8 to 43 per 100,000 population with a pSince long time, Indian farmers have been facing a number of socioeconomic problems, such as harassment by moneylenders, inability to repay debts following crop loss, inability to get medical treatment for the family, etc. The problem is compounded by lack of positive and cooperative support from banks especially in the face of inclement weather and market fluctuations. Economic plight of farmers might be illustrated with the fact that a farmer having as much as 15 acres of land and hence considered a well off farmer in Vidarbha, with an average income of Rs 2700 per acre per annum, had an income just little more than what he would have earned the legal minimum wage for all 365 days of the year.Agriculture is the main stay of the state of Maharashtra. Total irrigated area which had been used for cultivation is 33,500 sq kilometers. Average annual profit from cultivation in the state of Maharashtra is the lowest of all Indian states, lagging far behind the state with the highest - Jammu and Kashmir . The reasons for such a pathetic state of farmers include below average rainfall, heavy load-shedding, lack of small irrigation projects, poverty, pressure of private moneylenders and banks, ignorance of ancillary occupations for raising income, employment problem of the farmers' children, decreasing interest of the young generation in farming, rapid urbanization, apathy and lack of political willpower toward welfare and development of the region, etc. Cumulative effect of all these is evident on the psyche of the people of Vidarbha in general and farmers in particular. Farmers are hence prompted to turn to local moneylenders (sahukars) who charged them a much higher rate of interest. In fact moneylenders proved to be the most common and easy source of loans for the farmer (28.4%) followed by loans procured from relatives (22.93%) while only 3.94% turned to land development banks.In a country of 70 million farmers, it is 10 in every 100,000 farmers committing suicide. This is higher than the total national suicide rate. The numbIn India, the national data show that suicide rate was 9.7/lakh population in 1995. suicidesWardha district in particular is also facing this problem with increasing number of claims for government ex gratia grant on steady rise. In 2008 Vidarbha is home for approximately 3.4 million cotton farmers and 95% of these are struggling with the massive debt. Most of the villages in Vidarbha are badly in need of basic social infrastructure like all-weather roads, drinking water, regular electricity, primary health care, and basic education. Majority of suicide cases are from cotton growing areas. The cotton farmers in India paying more prices for inputs like seeds, pesticides, fertilizers, electricity, water, and labor whereas the price of cotton has gone down along with decreased productivity. In contrast to this picture in India, US Government is giving USD 4.0 billion to cotton farmers and asking for further liberalization of cotton trade in USA.absence of adequate social support infrastructure at the level of the village and district,uncertainty of agricultural enterprise in the region,indebtedness of farmers,rising costs of cultivation,plummeting prices of farm commodities,lack of credit availability for small farmers,relative absence of irrigation facilities,repeated crop failures,dependence on rainfall for farming,rural living and easy access to poisons, andlack of political will and insight in the region.As discussed earlier, some of the important contributing factors for farmers' suicide in this region are:In Vidarbha , the major crop is cotton, jowar (Barley), and pulses and people rely more on dry farming. Irrigated farming is insignificant and seen only in very few pockets where major rivers provide water for the whole year.With the cumulative effect of these reasons coupled with environmental antagonism and exploitation of the farmers in all sectors made them pessimistic toward life resulting into development of suicidal tendency in them. The remedial measures undertaken by the government did not show any immediate positive effect in the attitude of the farmers. In April 2007, an NGO named Green Earth Social Development Consulting brought Farmers' demands were not taken into count while preparing the relief package. Neither were civil society organizations, local government bodies, panchayats, etc. consulted.The relief packages were mostly amalgamations of exiting schemes. Apart from the farmer helpline and the direct financial assistance, there was scarcely any thing new being offered. Pumping extra funds into additional schemes shows that no new idea was applied to solve a situation where existing measures have obviously failed.The farmer helpline did not give any substantial help to farmers.The basis for selection of beneficiaries under the assistance scheme was not well defined. Also, type of assistance to be given led to problems like a farmer needing a pair of bullocks getting a pump set and vice versa (or a farmer who has no access to water sources being given pump sets).The report's conclusions were:Awareness regarding the package was also pretty low. The report concluded quite alarmingly that the loan burden of the farmers will double in 2008.The Department of Psychiatry, Mahatma Gandhi Institute of Medical Sciences, Sewagram, had conducted a study on farmers who committed suicide between January 2005 to March 2006 in Wardha district . Verbal autopsy was implemented as a tool of investigation. It is a recognized vital tool in suicide investigation and planning intervention strategies. A structured enquiry form consisting of 52 questions was developed. It consisted both close and open-ended questions. Family members of farmers or landowners who had committed suicide during the above specified period were interviewed. The interview included a case history taken by trained doctors and it revealed a glimpse into the causes and circumstances behind these deaths. After the interview, the family members were given counseling. CounseliFarmers are in severe distress and there is an urgent need for increased public awareness among farmers regarding agricultural policies both financial and those extended by the government. If given an option, 40% farmers said that they would like to quit agriculture and take up some other carrier. It is a complex task and requires more than just throwing money at it. Surely, other measures will be needed to set the rural economy on track. Marketing and storage infrastructure will have to be built. New crop patterns that answer to emerging needs will have to be introduced. Better rural credit delivery system will have to be evolved. Self-help groups need to be encouraged.Finally, suicide should not be viewed as only mental health problem, which is a common notion among people. The various factors which play are: (1) chronic indebtedness and inability to pay interest accumulated over the years, (2) economic decline leads to complications and family disputes, depression, and alcoholism, etc., (3) compensation following suicide (death) helps family to repay debt, (4) grain drain, and (5) the rising costs of agricultural inputs and falling prices of agricultural produce.In the Indian situation, the causes are multifactorial, cumulative, repetitive and progressive, leading an individual to a state of helplessness, worthlessness and hopelessness, obviously influenced by his social strengths, and weaknesses along with his mental health status.Religious leaders have a major role to play in suicide prevention since all religions discourage the act of suicide. In this context, especially support provided by Hindu religious values in India is a strong protection against suicidal behavior. So indeed, it is very difficult and needs courage to commit suicide especially by farmers. Blaming only moneylenders, as if they have become plastic bags of rural economy is not the solution. We need to address actual reasons of suicide. There should be a committee, not only of agriculturists, economists, but also psychiatrists and social workers as well. Forming self-help group in every 4–5 villages will help. Suicide in farmers is a public health problem having no borders. It needs immediate and serious intervention.


While the number of new detected cases of HAT is falling, say the authors, sleeping sickness could suffer the "punishment of success," receiving lower priority by public and private health institutions. In the early part of the twentieth century, human African trypanosomiasis (HAT), also known as sleeping sickness, decimated the population in many parts of sub-Saharan Africa. In the 1930s, the colonial administrations, conscious of the negative impact of the disease on its territories, established disease control programmes. Systematic screening, treatment, and follow-up of millions of individuals in the whole continent led to transmission coming to a near halt by the 1960s.With the advent of independence in most countries where HAT was endemic, the newly independent authorities had other priorities to deal with. The rarity of HAT cases, and a decline in awareness of how the disease could return, led to a lack of interest in disease surveillance. Over time the disease slowly returned, and some thirty years later, flare-ups were observed throughout past endemic areas .Since 1995, the World Health Organization (WHO) has on many occasions expressed its concern about the rise in HAT cases. The World Health Assembly has passed several resolutions in an attempt to stem this rise. However, social upheavals, wars, and population movements, combined with lack of awareness and shortage of funds, prevented any progress in interrupting transmission, and the disease continued to evolve and spread.In a 1997 resolution, WHO strongly advocated access to diagnosis and treatment and the reinforcement of surveillance and control activities, concurrently setting up a network to strengthen coordination among all those actively concerned by the problem [Trypanosoma genus. Parasites are transmitted to humans by the bite of a tsetse fly (Glossina genus) that has acquired the infection from human beings or from animals harbouring the human pathogenic parasites  developed in 1978 is widely used for screening the population affected by nfection . Diagnosrhodesiense pentamidine for first-stage gambiense melarsoprol for the second stage of both forms of the disease, and eflornithine, which is only effective in the second stage of the gambiense form. The management of patients using any of these drugs is cumbersome and risky, requiring well-trained staff.Treatment today relies on four parenteral drugs: suramin for first-stage Despite success in reducing the number of cases reported, the complexity of the current tools available to control the disease does not allow the full involvement of the health care system, hampering the sustainability of HAT surveillance and control as discussed below.In early 2006, WHO published an update on the disease situation and ongoing control activities in each of the 36 countries considered endemic for HAT [gambiense form  responded well to intensive control activities mainly focused on the human reservoir . The number of people under active surveillance increased, and the number of new cases decreased  were found insufficient to control the disease, probably due to the role played by the animal reservoir on transmission. Thus, T. b. rhodesiense showed only a small decrease in the number of cases  have National Sleeping Sickness Control Programmes and carry out regular control activities. Four countries, with well-established Control Programmes and regular control activities, have reported more than 100 but less than 1,000 new cases per year, representing 8.8% of the total gambiense cases reported. Finally, three countries have reported an average of more than 1,000 new cases per year during the period from 1997–2006; together they represent 89.9% of the total gambiense cases reported  summit held in Lomé, Togo, the African Heads of State and Government adopted the decision to collectively embark on a Pan African Tsetse and Trypanosomosis Eradication Campaign (PATTEC). This campaign was based on the realisation that (1) solving the tsetse fly and disease problem would be an important contribution to Africa's development, and (2) this could not be done by a single country acting alone. A task force of African experts concluded that such a campaign was not only technically feasible, but economically productive .Implementation is on its way; six countries have recently received financial support from the African Development Bank and have initiated the first phase of a PATTEC project. In addition, four countries in the Kwando/Zambezi region have begun PATTEC activities, with very encouraging results.and health care systems, rather than falling back on the former debate between the value of specialised teams or primary health care. In other words, specialised teams and primary health care need to work together synergistically [The challenge for the immediate future is to avoid repeating past mistakes, and to achieve cost-effective, sustainable HAT surveillance and control. Sustainability can only be achieved through an integration of activities in a strengthened health system able to face such responsibilities. The current approach should include specialised teams stically .But integration is not a simple delegation process. Major responsibilities cannot simply be passed on to the existing health services of remote rural areas inappropriately trained and equipped to handle HAT control. Integration must mean the active participation of a strengthened health system capable of implementing surveillance and control activities, buttressed by specialised HAT national staff. Unfortunately, the existing tools limit the full participation of the health care system staff in controlling the disease. The two main technical bottlenecks are the lack of a sensitive and specific diagnostic test and of a new drug that is cheap, safe, and easy to administer.T. b. gambiense but in areas affected by T. b. rhodesiense disease control cannot rely exclusively on human health services and will have to involve veterinary and entomological services as well.To sustain recent achievements in HAT control and the epidemiological downward trend, it will be necessary to develop a novel approach for surveillance and control adapted to the new requirements. This approach consists of an integration process involving national health care systems. Implementation, however, will require better tools than those presently available for diagnosis and treatment. Such a health systems–based approach may be adequate for areas affected by T. b. gambiense and T. b. rhodesiense have been identified [Attempts to identify new antigens should result in more specific and sensitive tests for serodiagnosis of the disease, while changes in test format  should entified  for PCR-entified , and theentified  are encohttp://www.finddiagnostics.org/) to develop new simple diagnostic tools for the control of HAT that meet the requirements of a sustainable elimination approach. The desired characteristics of a new test were defined as being “ready for use”, stable at room temperature, and affordable by national health systems. The new test should provide an uncontroversial diagnosis of both forms of the disease and require minimum training and equipment to allow its execution by any health worker.Disease bio-markers are being investigated using proteomics, such as surface-enhanced laser desorption/ionisation time-of-flight mass spectrometry (SELDI-ToF-MS) . HoweverAs long as there is no safe and effective drug available to treat both stages of the disease, determining disease stage will remain necessary. Some progress has been made through the development of a point-of-care card agglutination test for immunoglobulin M quantification in cerebrospinal fluid . AlthougAnother possible technique for the diagnosis of central nervous system involvement is the measurement of sleep-onset rapid eye movement by polysomnography, a method that involves assessing the sleep pattern of patients . Howevergambiense disease in 1990. While the drug is safer than melarsoprol [Eflornithine was developed over 20 years ago, and was registered for the treatment of arsoprol , eflorniRecently a short-course melarsoprol treatment was developed ,21. UnfoT. b. gambiense and would certainly not be safe enough to be used in first-stage patients; thus it will not help in avoiding the risky staging process.With the development of parasite resistance to some of the available drugs , a numbeA new oral drug called DB289 is in the final clinical trial phase. Given its oral administration, it should be considered an important step forward. Unfortunately, the drug requires ten days of treatment, twice a day, and is only effective in the first stage. Consequently, DB289 cannot be considered a new drug that would be a major advance in control of HAT.The major challenge in developing a new drug that can ensure sustainable disease control will be to find a safe and affordable, orally administered drug that is effective against both forms of the disease, in both disease stages, and that does not require any particular skills or care to administer. The ideal regimen should not last more than a few days, thus making it manageable by peripheral health staff in an out-patient context.Current vector control interventions involve the use of insecticides , for example, in Unguja Island in Zanzibar [The SIT, which involves the release of laboratory-reared and sterilised males to compete with wild males so that females inseminated by them produce no offspring, has been effectively used for eradication of tsetse  the participation of existing health systems is not only desirable but essential for surveillance and control sustainability; (2) the development of new diagnostic tools and drugs is crucial to guarantee the effective participation of existing health structures; and (3) the maintenance of a specialised central structure at national level is necessary to ensure the coordination and overall technical assistance needed. In that context, WHO is ready to take up the challenge and continue to lead countries, supporting and coordinating the work of all the actors involved.


The WISEWOMAN program targets low-income under- and uninsured women aged 40–64 years for screening and interventions aimed at reducing the risk of heart disease, stroke, and other chronic diseases. The program enters its third phase on June 30, 2008. Design issues and results from Phase I and Phase II have been published in a series of papers. We summarize remaining challenges, which were identified through systematic research and evaluation. Phase III will address these challenges through a number of new initiatives such as allowing interventions of different intensities, taking advantage of resources for promoting community health, and providing evidence-based interventions through the program's Center of Excellence. Finally, we provide a framework and vision so that organizational, community, and other partners can make the case for the importance of the program to their communities and for what is needed to make it work. The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) ,2 prograPhase I of WISEWOMAN (1995–1998), which focused on research only, tested whether enhanced lifestyle interventions were more effective than lifestyle interventions using minimal or usual care. Design issues and results from this phase have been covered in a series of articles -6. DurinWISEWOMAN has identified lessons learned through randomized controlled trials ,6, nonraIn Phase II, performance indicators for nonresearch projects included screening 2500 women annually and ensuring that 75% of screened participants began the lifestyle intervention, that 60% of women starting the intervention completed it, that 75% of women screened were rescreened within 10–14 months, and that 95% of women with systolic blood pressure >180 mm Hg or diastolic blood pressure >110 mm Hg were seen within 1 week of screening. Programs varied substantially in their ability to meet performance indicators. For example, the number of annual screenings performed by programs ranged from 449 to 5629, and initiation of lifestyle interventions ranged from 16% of participants in the lowest-performing program to 100% in the highest-performing program . Although the highest-performing programs demonstrated that most of the performance indicators are achievable, the WISEWOMAN program decided to revisit the feasibility of using these indicators and to identify obstacles to reaching them.www.cdc.gov/wisewoman).In an example of the mixed-methods approach, investigators conducted case studies of the sites that had the highest and the lowest public health impact within a select number of states and tribes ,12. FromP < .05), total cholesterol , smoking , and 10-year risk of coronary heart disease  . In the subgroup with abnormal screening values at baseline, these reductions were even more striking .Target geographic areas in each state and tribe with the highest death rates and hospital discharge rates for heart disease and stroke.Deliver effective behavioral counseling based on sound theoretical approaches.Tailor lifestyle interventions according to degrees of risk for heart disease and stroke and readiness-to-change behaviors.Maximize the number of women being reassessed to determine whether their risk for heart disease and stroke has decreased and their health behaviors have improved.Collaborate with state, local, and community partners who can make policy, environmental, and system changes that support the adoption and maintenance of heart-healthy behaviors by underserved populations where they work, live, and play.These challenges will be addressed through the requirements published in funding announcements, stronger program guidance, clarified program vision and goals, new performance indicators, and evidence-based technical assistance and training. As in the past, WISEWOMAN will use a variety of evaluation methods to determine the degree to which these key challenges have been met.Most of the remainder of this article addresses two specific priorities: increasing the reach of the WISEWOMAN program and ensuring the effectiveness of its projects. Reach and effectiveness are the two criteria most directly related to determining WISEWOMAN's impact and thus merit extensive discussion. First, however, we focus on the importance of having a clear programmatic vision.Recent evidence from implementation of the Chronic Care Model ,20 suggeThe WISEWOMAN program employs the models used by Abrams et al  and Glaswww.effectiveinterventions.org).Another issue to be clarified involves approaches to implementing an intervention. Projects were required to select an evidence-based intervention, but ongoing guidance was not provided on tailoring interventions to new target populations or unique settings. Consequently, many projects did not faithfully implement the elements of their intervention that were credited with its effectiveness. Faithfully implementing these core elements is important, as demonstrated by the translation work of CDC's Division of HIV/AIDS Prevention, the Center on AIDS and Community Health, and the Academy for Educational Development   screening of risk factors for cardiovascular disease and other chronic diseases, 2) lifestyle interventions, 3) assurance of access to needed treatment and medication, and 4) follow-up visits for monitoring and evaluation. These components are required by congressional legislation. The clinical guidelines that are the source of the evidence for each of these four components  include One approach to expanding the reach of WISEWOMAN is to better match participants' needs with the program resources. Various interventions tailored to participants' degrees of risk or readiness to change might be the best way to proceed, or interventions might be designed to reduce costs per woman served. During Phase II, CDC asked that all participants be required to attend the same lifestyle intervention regardless of how strong their risk factors were or how ready they were to change. For many reasons, however, designing only one intervention for all women can limit a program's reach. Furthermore, women with normal screening values will most likely not need an intensive intervention designed to control risk factors, nor is it reasonable or cost-effective to ask a woman who is not ready to change to participate in a costly intervention. Referring women with highly abnormal screening values to low-intensity interventions that may not help control their risk factors is also likely to be ineffective.Because women often describe time as the major barrier to participation in public health programs , asking www.wiseinterventions.org). Evaluation will focus on monitoring the implementation of core elements.Scientists have debated the degree to which every aspect of an intervention must be delivered exactly as it was in the randomized trial that demonstrated its effectiveness . An extrFor the practitioner, CDC's state and tribal partners, and CDC staff, knowing how to deliver a program is often the most difficult challenge. The various levels of the socioecologic model dictate different strategies for change. For example, the WISEWOMAN program endorses the 5A's strategy   for creaAt the organizational and community level, we will use the following steps advocated by Kotter  Figure  to encouCreating community and policy changes using Kotter's approach means first establishing a sense of urgency among community leaders about providing financially disadvantaged populations with access to resources and ensuring social and environmental support through such activities as creating walkable environments in the lowest-income neighborhoods. For policy changes, the initial task of creating a sense of urgency can involve issues such as universal access to preventive health services and the expansion of successful health promotion programs statewide.When it enters its implementation phase (Phase III), WISEWOMAN will be moving in some new directions. To extend reach and reduce costs, the program will help projects design interventions based on degrees of risk and levels of motivation and will ensure that projects have access to resources for promoting community health. These strategies are also likely to increase the effectiveness of the program. For example, one strategy has CDC providing evidence-based interventions and core elements through the Center of Excellence that conducts research on improving the public health impact of the WISEWOMAN program. Another strategy for increasing effectiveness is the provision of a clear framework and vision so that organizational, community, and other partners can make the case for why the program is important to their communities and what is needed to make it work.Moving in a new direction always presents challenges. For WISEWOMAN, some of these challenges are ensuring that underfunded sites are not overburdened by having to conduct multiple interventions, measuring readiness to change when addressing multiple behaviors, packaging new interventions and updating old versions, monitoring projects for faithful implementation of core elements, and ensuring that women with normal screening values receive appropriate counseling and resources. Acknowledging these challenges, CDC looks forward to Phase III and hopes to be able to demonstrate the impact of these new directions through increased services to a greater number of women and a reduction in heart disease and stroke.


There is increasing focus on patient-centred communicative approaches in medical consultations, but few studies have shown the extent to which patients' positive coping strategies and psychological assets are addressed by general practitioners (GPs) on a regular day at the office. This study measures the frequency of GPs' use of questions and comments addressing their patients' coping strategies or resources.Twenty-four GPs were video-recorded in 145 consultations. The consultations were coded using a modified version of the Roter Interaction Analysis System. In this study, we also developed four additional coding categories based on cognitive therapy and solution-focused therapy: attribution, resources, coping, and solution-focused techniques.The reliability between coders was established, a factor analysis was applied to test the relationship between the communication categories, and a tentative validating exercise was performed by reversed coding.Cohen's kappa was 0.52 between coders. Only 2% of the utterances could be categorized as resource or coping oriented. Six GPs contributed 59% of these utterances. The factor analysis identified two factors, one task oriented and one patient oriented.The frequency of communication about coping and resources was very low. Communication skills training for GPs in this field is required. Further validating studies of this kind of measurement tool are warranted. Over the last few years, we have seen an increasing focus on patient centeredness and shared decision making in primary care . The resPatient involvement is further refined in the field of psychotherapy. Several current psychotherapeutic methods aim to help patients overcome and resolve problems by using a patient's own resources in different ways, e.g., solution-focused therapy .Our research group is involved in the development and assessment of training general practitioners (GPs) in communication skills. We emphasize skills that enhance patients' awareness of and focus on their own resources, in addition to the general biomedical focus of the consultation. When we started to develop a communication skills training programme, we assumed that it is relatively rare in general practice for the physician's communication behaviour to be systematically directed towards a patient's resources and coping strategies. However, this assumption was based on anecdotal evidence. Although several studies have documented the amount of psychosocial content of consultations, they have not specified how much of the psychosocial content is focused on patients' personal resources and coping behaviour rather than on their psychological distress and other problems ,5. We coTo the best of our knowledge, none of the existing methods of interaction analysis in medical interviews specifically assesses this sort of communication in the desired detail. Consequently, we developed an approach to interaction analysis in terms of a one-channel system, and coded all GP communication to quantify the number of times a GP states a question or a comment or gives an explanation, according to specific content categories.We took as the point of departure the system most frequently applied to measure the doctor-patient interaction, the Roter's Interaction Analysis System (RIAS) . Because1. Can resource- and coping-oriented communication by a physician (ARCS), as defined by the interaction analysis system, be reliably and validly measured based on the video analysis of medical interviews?2. How frequently do units of resource- and coping-oriented communication (ARCS) by a physician occur in consultations in general practice?3. How is resource- and coping-oriented communication (ARCS) by a physician related to the more general categories of doctor communication, as measured with RIAS?Eighty GPs in the municipality of Bærum, Norway, were invited to participate in the study, without having to pay for the training. After a baseline assessment of the physicians' communication behaviour in the consultations, the participants would take part in a communication skills training program, followed by a second assessment of their communication. A thorough description has been submitted for publication elsewhere. The training programme was approved by the Norwegian Medical Association as part of the training that leads to the accreditation or the continued accreditation of specialists in general medicine. Hence, the sample is a convenience sample based on a window of opportunity in the community and on decisions made by the local health authorities. We wanted as many GPs and patients as possible to participate in the study.Twenty-seven GPs were enrolled in the study. After enrolment, three GPs withdrew from the study, leaving 24 GPs enrolled, nine women and 15 men. Each GP chose a day for the video recordings within a one-month time period. Each GP sent out invitations, including informed consent forms, to all the patients who had appointments for consultations on that day, one week in advance. The excluded patients were more than 80 years old or less than 18 years old, and those patients who had booked immediate-assistance consultations on the same day. This resulted in a total number of 145 patients in the study, with a mean number of six patients per GP.The two most common traditions in measuring physician-patient communication behaviour are utterance-by-utterance coding and rating-scale techniques . We deciThe overall physician communication behaviour in all 145 consultations was coded according to a modified version of RIAS. We collapsed several categories of the RIAS system, making the categories broader. These were collected into 10 categories, which we refer to as "general RIAS communication codes". Collapsing categories is the rule rather than the exception in studies like this [In operationalizing the physician content with reference to a patient's personal resource issues for the coding scheme, we chose a series of content categories that we considered to correspond a priori to specific aspects of the content in the area of personal resources, partly on the basis of the principles of solution-focused therapy  and CBT We analysed GP speech in terms of utterances and turns. An utterance was defined as the smallest meaningful verbal expression. The next level of analysis in the conversation is the "turn". A turn is when the GP talks, "has the floor", and drives the communication. A turn may consist of only one utterance, but it normally includes several utterances.Our default unit of coding was the turn. If the same code could account for the whole turn, the turn was coded as one unit. If the coding category content changed within the turn, more than one code was applied to that turn.Minimal expressions from the doctor in terms of back-channelling continuers  during a patient's turn were not coded .Kappa was used to test the reliability of the distinction between the ARCS codes and the general RIAS codes. A team of five coders met to discuss the content of and the inclusion and exclusion criteria for each of the categories. The team then commenced a series of meetings in which individually coded consultations were recoded during a discussion of the coding practice (consensus coding). Detailed definitions of the categories were further developed through discussion. At every meeting, Cohen's kappa values  were meaAll consultations that had been part of the consensus coding were included in the pool of consultations and recoded approximately five months after the first review. This was done because the base rate of the resources communication in the material was low and also because there was no other material to use for the coding exercises.An important aspect of validity in the measurement of communication is the extent to which the measured communication taps the meaning of the theoretical definition. To understand more about this validity issue, we performed a reversed coding exercise. This exercise was used to demonstrate that there was no conceptual contamination between the ARCS categories and the general RIAS communication categories. Five researchers, experienced in the communication skills training of medical students but without any knowledge of the assessment concept, were given an overview of the names of all the communication categories we had originally used, for all 16 categories (collapsed RIAS and ARCS categories), together with two cards from each category: one definition and one criterion card. The cards were presented in random order. The researchers were then asked to categorize the cards under the correct category label, together with the correct behaviour criterion.During coding, the category "residual, unintelligible" was added. In the statistical analysis, the four sub-categories comprising the C-code were merged into one code because they were used infrequently in the consultations. This resulted in the 14 categories presented in Tables To test the communication patterns in the use of the ARCS categories and the general RIAS codes, we conducted a factor analysis  of all 145 consultations and all communication categories, except for the "shows disapproval" and "residual, unintelligible" categories. These were excluded because of the low sample number, and the lack of relevance for the analysis. The numerical requirements were met with an n value of more than 10 times the number of items in the analysis.Observer XT, version 6.4.1, was used for coding . StatistThe study was approved by the regional committee for research ethics and the Norwegian Social Science Data Services.Ten percent of all consultations were coded in the reliability test. There was agreement across coders that 1778 utterances should be coded with non-ARCS codes, whereas 25 utterances should be coded in the ARCS categories. There was disagreement on 45 utterances, coded as ARCS utterances by one of the coders. When the agreed codes (1778 and 25) were added and divided by the total number of coded utterances (1848), there was 98% agreement among the coders. The reference coder applied a consistently more conservative coding. Cohen's kappa was 0.52.With two exceptions, all cards were classified correctly. One coder mixed the definitions of two general RIAS codes; another coder similarly mixed two of the ARCS codes. Thus, there was no misclassification across the general RIAS codes or the ARCS codes.A total of 8741 utterances were coded for the 25 GPs during 145 consultations. The frequencies of each of the measured communication categories are presented in Table The scree plot indicates a two-factor solution. The first factor, which accounted for 24.6% of the variance, consisted of all the ARCS codes, questions, and information on psychosocial and lifestyle issues and empathy. The second factor, which accounted for 18.7% of the variance, consisted of the facilitation category and task-oriented RIAS communication codes , as well as the category "gives orientation". Social talk did not load either factor. The results are presented in Table P < 0.051) between the use of the ARCS codes and the total number of coded behaviours per consultation.The use of ARCS communication categories was not evenly distributed among the GPs. There was a borderline significant correlation (When we aggregated the scores to control for the length of the consultation in terms of the number of coded utterances, six GPs contributed 59% of the ARCS codes in the material. No other distinguishing factor in the available data was identified among those six GPs.This study indicates that the communication by the physician that emphasizes the personal resources and coping strategies of a patient occurs relatively seldom in general practice, representing 2.1% of the GP's utterances in an average consultation.There are many communication measurement tools available, many with established measures of reliability and validity . A recenA kappa value of 0.52 between the proper coders and the reference coder is considered fair, given the review by Bakeman . HoweverIt is interesting that so little of the psychosocially oriented content was related to a patient's personal resources or coping behaviour. The data indicate that the agreement was least between the ARCS codes and the GP's questions and information on lifestyle and psychosocial issues. If the special ARCS codes had not been applied, most of the utterances coded in the ARCS categories would have been coded as questions and information on lifestyle and psychosocial issues. These two coding categories represented 23.2% of all utterances.The tentative validation exercise for the ARCS categories in this study is only a validation to the extent that it describes the utterances as observed communication intended to help a patient focus on their resources and coping strategies. Whether this is actually the case or not is another issue. To answer this, we would have had to have asked the patients, which was beyond the scope of this study. However, the reversed coding exercise clearly indicated that the meanings of the descriptive words and phrases used in the coding scheme were correctly understood by the professionals in the field.The ARCS communication was used in 2.1% of the consultations in this study. This frequency warrants two remarks. A measure of frequency does not say anything about the importance or relevance of the communication. In terms of a rare communicative phenomenon, it is often argued by others that, for example, the low frequency at which patients express their emotional cues and concerns is hugely important, even though such expression is a rare phenomenon . In our In terms of a biomedical regime, 2.1% might seem appropriate. However, studies have shown that as many as 50% of patients visiting a GP have no biomedically explicable symptoms . From thThe discussion by physicians on personal resources and coping strategies is part of a general pattern in consultations. Factor analysis indicated that in consultations in which the ARCS categories are used, the GPs tended to ask more questions and supply more information about psychosocial and lifestyle issues, and to make empathic statements. We labelled this general communication pattern "patient-centred communication". How can we understand this?ARCS communication is not a "decision aid" per se , becauseThe ARCS communication categories may be considered patient-centred , but theThis study must be considered a pilot study, undertaken to extend our knowledge of specific communication patterns directed towards a patient's resources and coping strategies in general practice. In addition to the abovementioned arguments, we must keep in mind that this study was conducted in a specific suburban area. The participating GPs were not randomly selected, but were invited based on their geographic location. A study from the UK indicated that GPs who agree to be video recorded might differ from non-participating GPs . AnotherRegardless of its frequency, the presence of ARCS communication does not give any information about the quality of care, because that would require a qualitative analysis of the purposefulness or other effect measures. The ARCS communication appears in a particular context, that is, together with more patient-oriented non-biomedical communication, as in factor 1 of the factor analysis. Because of the low base rate of ARCS utterances and the very large standard deviations of these utterances, we must be careful in drawing conclusions based on this factor analysis.In this study, discussion by the physician that emphasized the personal resources and coping strategies of a patient was a rare phenomenon. Based on our data, we draw a two-fold conclusion: more communication skills training is needed by GPs to provide them with communication tools designed to address patients' resources and coping abilities, and further studies are required to validate the measurement of these communication categories.GP: general practitioner; RIAS: Roter Interaction Analysis System; ARCS: attribution, resources, coping, and solution-focused techniques; UK: United Kingdom; CBT: cognitive behavioural therapy.The authors declare that they have no competing interests.TM and AF contributed equally to the statistical analysis and the writing of the article. Both authors read and approved the final manuscript.Cand. Psychol. TM is a doctoral fellow and Dr. Philos. AF is a professor in medical psychology.The pre-publication history for this paper can be accessed here: