Cardiovascular disease is the leading cause of disability and mortality in most Western countries. The prevalence of several risk factors, most notably low physical activity and poor nutrition, is very high. Therefore, lifestyle behaviour changes are of great importance. The worksite offers an efficient structure to reach large groups and to make use of a natural social network. This study investigates a worksite health promotion programme with individually tailored advice in physical activity and nutrition and individual counselling to increase compliance with lifestyle recommendations and sustainability of a healthy lifestyle.The study is a pragmatic cluster randomised controlled trial with the worksite as the unit of randomisation. All workers will receive a standard worksite health promotion program. Additionally, the intervention group will receive access to an individual Health Portal consisting of four critical features: a computer-tailored advice, a monitoring function, a personal coach, and opportunities to contact professionals at request. Participants are employees working for companies in the Netherlands, being literate enough to read and understand simple Internet-based messages in the Dutch language.A questionnaire to assess primary outcomes  will take place at baseline and after 12 and 24 months. This questionnaire also assesses secondary outcomes including fat intake, self-efficacy and self-perceived barriers on physical activity and fruit and vegetable intake. Other secondary outcomes, including a cardiovascular risk profile and physical fitness, will be measured at baseline and after 24 months.Apart from the effect evaluation, a process evaluation will be carried out to gain insight into participation and adherence to the worksite health promotion programme. A cost-effectiveness analysis and sensitivity analysis will be carried out as well.The unique combination of features makes the individually tailored worksite health promotion programme a promising tool for health promotion. It is hypothesized that the Health Portal's features will counteract loss to follow-up, and will increase compliance with the lifestyle recommendations and sustainability of a healthy lifestyle.Current Controlled Trials ISRCTN52854353. Cardiovascular disease (CVD) is the leading cause of disability and mortality in most Western countries. CVD causes nearly half of all deaths in Europe (49%) . Major mAccording to a survey in European Union countries in 2002, 56% of the Dutch population over 15 years was insufficiently physically active for health . In 2006The results of a recent meta-analysis on cohort studies indicate that fruit and vegetable consumption is inversely associated with the occurrence of coronary heart disease. The risk of coronary heart disease decreased by 4% for each additional portion of fruit and vegetables per day . In the The imbalance between PA and nutrition is an important cause of overweight and obesity, which in turn are important risk factors for CVD . In the In the prevention of cardiovascular disease, lifestyle behaviour changes are of great importance. Worksites have specific features that make them a promising place for health promotion. Worksites offer an efficient structure to reach large groups, enable the introduction of social support, and make use of a natural social network for peer support ,14.Literature shows contradictory results of randomised controlled trials (RCTs) on worksite health promotion programmes (WHPPs). A recent systematic review concluded that there is strong evidence for effectiveness of WHPP, based on two RCTs with a small effect on exercise behaviour and on energy expenditure . HoweverThe overall picture emerges that WHPP may increase PA and improve nutritional intake among targeted groups, depending on the critical features of the interventions. Amongst others, as success factors of WHPP have been identified: (1) interventions tailored to the individuals' readiness for exercise adoption, (2) programmes that integrate specific components  into a combined approach, and (3) linking individual approaches to environment and policy conditions . Marcus In contrast, three factors have been identified as greatest risks for ineffective WHPP: (1) a low, selective participation, (2) lack of adherence to the WHPP, and (3) an intervention effort too short for sustainable change in behaviour ,15,16. IIn conclusion, previous WHPPs have shown contradictory results. Studies are needed on a WHPP that counteracts the three main factors for ineffectiveness.In the study protocol described in this article, a long-term WHPP will be evaluated that adds the following four critical features to a traditional WHPP: (1) a computer-tailored advice on PA and diet (to increase awareness and adherence to the WHPP) (2) insight in progress over time on health-related behaviours , (3) continuous feedback and support through monthly e-mails  for 12 months (to increase adherence to the WHPP and compliance with and sustainability to the lifestyle recommendations), and (4) opportunities to seek personal advice from a variety of professionals (to increase adherence to the WHPP).The aim of this pragmatic cluster randomised controlled trial is to evaluate the cost-effectiveness of a new investigator-driven WHPP with individually tailored advice in PA and nutrition and individual counselling to increase compliance with the lifestyle recommendations and sustainability of a healthy lifestyle.The study is a single blind pragmatic cluster randomised controlled trial with the worksite as the unit of randomisation. The  intervention is targeted at the individual level. The study population consists of workers in companies that offer a standard WHPP to their employees, as provided by an organisation specialized in health management . Eligibility criteria for individual workers in the study are: 1) paid employment, 2) working at least 12 hours a week, and 3) being literate enough to read and understand simple e-mail and Internet-based messages in the Dutch language. All participants are blinded to the type of intervention. Data collection starts in September 2007 and will continue until August 2010. Participants will be requested to fill out a questionnaire at baseline and after 12 and 24 months. A physical examination  will take place at baseline and after 24 months. The study design and participant flow are shown in Figure Within each company, units will be randomised by a researcher not involved in the study, based on a table of random numbers (SAS command Ranuni). Within each company, worksites with comparable work activities and a comparable number of workers will be randomly allocated to the intervention or the control group. Subsequently, workers within each unit will be asked to participate in the study, presented as an evaluation study of different types of WHPP. All participants from one worksite will be randomised together rather than individually because individual randomisation may lead to contamination of the control group. Written informed consent at individual level is collected after agreement of the employer and randomisation at cluster level. Since it is deemed not possible within companies to withheld participation in a WHPP, workers within the control group will receive a standard WHPP.The standard WHPP consists of:1) A questionnaire to assess, among other things, PA level and fruit and vegetable intake.2) A health check to assess weight, length, total blood cholesterol level, blood pressure, resting heart rate, body mass index (BMI), percentage of body fat, and predicted maximal oxygen uptake.3) Advice of the provider's personnel, based on the outcomes of the questionnaire and health check. In addition, workers with a high total cholesterol level or high blood pressure will be referred to their general practitioner.4) Access to a restricted part of the Health Portal on Internet, containing general information on health and health-related behaviours. The individual results on the questionnaire and health check are also retrievable through this web site.On top of the standard WHPP the intervention group will have full access to the personalized Health Portal on Internet. The Portal contains four critical features: a computer-tailored advice, a monitoring function, a personal coach, and opportunities to contact professionals at request.Participants will receive a computer-tailored advice to increase awareness of their lifestyle . AwareneAfter baseline measurements the participant in the intervention group will receive an email with the notification that a personal advice is available on the Health Portal. Considering the answers on the questionnaire filled out at baseline a personal advice on PA, fruit and vegetable consumption, and fat intake will be generated. The advice aims to increase adherence to the intervention and to motivate the participant to engage in PA and a healthy diet, and consists of the following parts:1) Personal feedback: feedback on to what extent the recommendations on PA and dietary intake are met.2) Action feedback: feedback on the specific barrier attributed by the participant as most important to not meeting the recommendations. The advice also contains opportunities to link to further information on the Health Portal and provides tips on how to meet the guidelines.If one meets the recommendations, only the personal feedback is provided. See Figure Second, a monitoring function is integrated in the Health Portal to increase adherence to the intervention programme and consequently increase compliance with the lifestyle recommendations and sustainability of healthy behaviour. Recent studies have shown that people who want to change their lifestyle should be encouraged to regularly monitor their progress in adopting a new behaviour ,26.With the monitor function individual progress charts on self-reported weight, BMI, PA, and fruit and vegetable intake will be generated. The results of the baseline measurements will be used as starting point. The frequency of the use of this monitoring function is at the discretion of the participant. After 12 months the progress will be evaluated and communicated as part of the intervention. See Figure The third critical feature of the Portal is a personal coach who will give continuous feedback and support through monthly emails. As like the monitoring function, this feature is part of the Health Portal to increase adherence to the intervention programme and to motivate participants to comply with the lifestyle recommendations and/or to maintain a healthy lifestyle. A previous study found promising results of individualized, interactive support for behaviour change on lifestyle .Three groups of participants will be distinguished, based on Health Portal use and lifestyle. First, participants who do meet the recommendations on PA and/or fruit and vegetable intake at baseline will receive automatically generated emails with support to maintain their healthy lifestyle. Second, those not meeting the recommendation and not using the Health Portal will receive a reminder, a single question whether they have changed their behaviour and an invitation to use the monitoring function. Last, participants who use the monitoring function, but did not meet the recommendation at baseline, will receive a personal, not automatically generated, email with feedback on the data imported in the monitor.If the participant does not want to receive the monthly emails, he can indicate this on the Health Portal.The fourth feature is the opportunity to seek personal advice from a variety of professionals. By sending a message via the Health Portal participants can consult several experts such as a personal coach, a physiotherapist, or a dietician. This function is added to the Portal to increase adherence to the intervention programme.The complete Health Portal will be offered for 12 months. After 12 months the monthly contact by a personal coach will be terminated, but access to the Portal will remain throughout the project.PA level will be assessed by the self-administered short version of the International Physical Activity Questionnaire (IPAQ) . The IPABoth categorical and continuous indicators of PA will be calculated. By multiplying the metabolic-equivalent (MET) intensity for each activity with the weekly duration (in minutes) spent on each activity, the continuous measure (MET-minutes per week) will be calculated as recommended in the IPAQ scoring protocol . The DutFruit and vegetable intake will be assessed by means of a self-administered nine-item validated Dutch Food Frequency Questionnaire . The queTotal fruit consumption and total vegetable consumption will be calculated in grams. The total scores will also be used to determine compliance with the recommendations of an average of 200 grams of fruit and 200 grams of vegetables a day.Self-efficacy concerning PA and fruit and vegetable intake will be determined by asking how confident participants are to engage in PA and fruit and vegetable consumption in the next month, rated on a Likert scale between 1 (certainly) and 5 (certainly not) .Perceived barriers concerning PA and fruit and vegetable intake will be assessed, by asking for the most important barrier to engage in these behaviours. The question on barriers to engage in PA has the following answer categories: not enough time/too busy, do not enjoy sports, too expensive, tired, fear of injury, no facilities at home, no facilities in direct environment, lack of a partner to exercise with, health problems, unsafe environment, and no barriers. The question on barriers concerning fruit and vegetable intake has the following categories: not enough time/too busy, not tasty, too expensive, no facilities at work to buy fruit and/or vegetables, no availability in the shops in the home environment, and no barriers.Fat intake will be assessed by means of a self-administered 35-item validated Fat list covering 19 (groups of) food products. Participants will be asked about the frequency of food items during the last month with fixed categories. For each of the 19 categories a fat score, ranging from 0 (lowest fat intake) to a maximum varying from 3 to 5 points (highest fat intake), will be determined. Scores on the Fat list are presented in points instead of grams of fat, as only the most important saturated fat sources were included in the questionnaire . A totalThe risk profile for cardiovascular events will be assessed by the SCORE  system, taking into account the following risk factors: sex, age, smoking, total cholesterol level, and systolic blood pressure . Sex, ag2). Waist circumference and thickness of three skin folds  will be measured to calculate body fat percentage.In addition to these measures length and body weight will be measured to determine BMI (kg/m2max). All the physical measurements will be done according to the guidelines for exercise testing of the ACSM [A submaximal exercise test on a bicycle ergometer will be conducted to predict maximal oxygen uptake, according to the American College of Sports Medicine's (ACSM) protocol, using three-minutes stages and terminates at approximately 80% of the age predicted maximum heart rate. The initial test workload will depend on age, sex, and exercise status. The maximum number of workload stages is four, and the minimum test time is nine minutes. Participants will be asked to pedal with a frequency of 60 revolutions per minute (rpm). During the test, heart rate will be recorded, and used to predict maximal oxygen uptake participants will be considered: age, sex, education, job title. In addition, enterprise size (number of employees) and history of health promotion activities in the company will be considered.Adherence to the intervention programme will be analysed in relation to compliance with lifestyle recommendations on PA and on fruit and vegetable intake, and in relation to sustainability of a healthy lifestyle. As markers of adherence to the intervention programme, the frequency of visiting the Health Portal, duration of stay on the Portal and frequency of contacts with professionals and personal coach will be registered. This will be done for the full Health Portal, as well as separately for the different parts of the Health Portal.In addition, characteristics of participants  will be analysed as to subgroups with the best adherence to the intervention programme, compliance with the lifestyle recommendations, and sustainability of a healthy lifestyle.The cost-effectiveness analysis will be performed from a societal perspective as well as a company perspective. The following direct costs will be determined: cost price of the standard WHPP, costs for the Health Portal and direct costs of medical consumption. Direct costs of medical consumption will be based on frequency of contacts with a variety of health professionals and average remuneration fee, assessed by an adapted version of the Dutch Trimbos and iMTA Questionnaire on Costs Associated with Psychiatric Illness (TiC-P) . The dirThe indirect costs will be based on assessment of days with loss of productivity at work due to health problems and productivity loss due to sickness absence, using the Dutch productivity and disease questionnaire (PRODISQ) . The estIn a second step cost-effectiveness ratios will be calculated on two measures of health: general health and the SCORE risk profile for cardiovascular events.The sensitivity analysis will start with the analysis of the effectiveness of the intervention in specific subgroups, most notably those workers with a low physical activity level, with a low intake of vegetables and fruit, and with a high body mass index. A sensitivity analysis will also be performed on the individual cost-effectiveness ratios by means of bootstrapping. This part of the sensitivity analysis will be used to determine the minimum level of effectiveness required to make the Health Portal more cost-effective than the standard WHPP.The assumptions for the power calculations were: an intra-cluster correlation of 0.05 (as observed in a previous cluster RCT in companies ), an aveAn intention-to-treat analysis will be used with last available information carried forward to missing data in subsequent measurements. A multilevel linear regression model with repeated measurements will be used (SAS proc Mixed) for continuous outcomes and a hierarchical logistic regression (SAS proc Genmod) for dichotomous outcomes. The effect of self-efficacy, environmental determinants, Portal use, and drop-out during follow-up on primary and secondary outcome measures will be evaluated for their potentially differential effects.Although the discriminatory power will be limited, an analysis will be carried out as to which subgroups participate in the WHPP and the Health Portal and which subgroups have the best adherence to the lifestyle recommendations .In addition, preliminary analyses will be performed for workers with cardiovascular complaints and workers with obesity in order to evaluate whether these subgroups are more or less amendable to changing their lifestyle.In this study protocol the design of a pragmatic cluster randomised controlled trial on worksite health promotion is presented. The study is designed to evaluate the (cost)effectiveness of an individually tailored long-term worksite health promotion programme on PA and nutrition. It is hypothesized that the unique combination of critical features  counteracts the main factors for ineffective WHPP , and leads to a change in lifestyle. By conducting an extensive process evaluation we gain insight into the effective elements of worksite health promotion. By registering several process variables it is possible to find out if participants with a higher adherence to the (separate parts of the) WHPP are more likely to comply with the lifestyle recommendations.With the health check as starting point for the WHPP, it is aimed to increase participation. The Health Portal's critical features are aimed to counteract loss to follow-up, and increase adherence to the intervention programme, compliance with lifestyle recommendations, and sustainability of a healthy lifestyle. Because of the long-term follow-up, sustainability of healthy behaviour will be facilitated.The cost-effectiveness of the extensive Health Portal will be compared to the cost-effectiveness of the standard WHPP.In conclusion, this study evaluates a promising intervention on healthy behaviour and results will provide insight into cost-effectiveness and the effective elements of WHPP.SR declares that she has no competing interests. AB has advised LifeGuard Inc. with respect to validity and reliability of questionnaires on working conditions, work ability, medical consumption and productivity losses in past. FB is Research and Development director at LifeGuard Inc.AB and FB originated the idea for the study and its design. AB was responsible for acquiring the grant for the study. SR further developed the described intervention protocol and will be responsible for data collection, data analysis, and drafting of the final research report. The authors participated in discussing the design of the study and developing the research protocols. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


This paper reports on a population-based sample survey of 2,289 children aged less than five years (under-five children) conducted in 2000 as a baseline for the Bangladesh component of the Multi-country Evaluation (MCE) of the Integrated Management of Childhood Illness strategy. Of interest were rates and differentials by sex and socioeconomic status for three aspects of child health in rural Bangladesh: morbidity and hospitalizations, including severity of illness; care-seeking for childhood illness; and home-care for illness. The survey was carried out among a population of about 380,000 in Matlab upazila (subdistrict). Generic MCE Household Survey tools were adapted, translated, and pretested. Trained interviewers conducted the survey in the study areas. In total, 2,289 under-five children were included in the survey. Results showed a very high prevalence of illness among Bangladeshi children, with over two-thirds reported to have had at least one illness during the two weeks preceding the survey. Most sick children in this population had multiple symptoms, suggesting that the use of the IMCI clinical guidelines will lead to improved quality of care. Contrary to expectations, there were no significant differences in the prevalence of illness either by sex or by socioeconomic status. About one-third of the children with a reported illness did not receive any care outside the home. Of those for whom outside care was sought, 42% were taken to a village doctor. Only 8% were taken to an appropriate provider, i.e. a health facility, a hospital, a doctor, a paramedic, or a community-based health worker. Poorer children than less-poor children were less likely to be taken to an appropriate healthcare provider. The findings indicated that children with severe illness in the least poor households were three times more likely to seek care from a trained provider than children in the poorest households. Any evidence of gender inequities in child healthcare, either in terms of prevalence of illness or care-seeking patterns, was not found. Care-seeking patterns were associated with the perceived severity of illness, the presence of danger signs, and the duration and number of symptoms. The results highlight the challenges that will need to be addressed as IMCI is implemented in health facilities and extended to address key family and community practices, including extremely low rates of use of the formal health sector for the management of sick children. Child health planners and researchers must find ways to address the apparent population preference for untrained and traditional providers which is determined by various factors, including the actual and perceived quality of care, and the differentials in care-seeking practices that discriminate against the poorest households. Bangladesh has witnessed remarkable declines in infant and child mortality in the last two decades. In the early 1980s, rates of mortality of children aged less than five years (under-five children) were as high as 200 per 1,000 livebirths. By 2000, the rate had declined over 50% to 94% per 1,000 livebirths -8.Inequities in the use of child health services and health status exist in many parts of the world .Results of analyses of the BDHS 1996–1997 by the Health, Nutrition and Population Programme of the World Bank showed significant differentials in care-seeking by wealth . For exaThe Integrated Management of Childhood Illness (IMCI) strategy brings together previous vertical programmes for the management of childhood illnesses. It encompasses skilled health workers in the first-level facilities, functioning, and supportive health systems that include supervision, adequate and sustained supply of drugs, effective referral systems, and engagement of families and communities in improving key practices . The strThe Government of Bangladesh officially adopted the IMCI strategy in 1998; however, it was only in late 2001 that pilot implementation began in two subdistricts. One of these subdistricts—Matlab—is also one of five global sites for the Multi-country Evaluation (MCE) of IMCI Effectiveness, Cost and Impact . The BanThe study was conducted in Matlab upazila (subdistrict) of Bangladesh, which has a population of about 500,000. ICDDR,B provides direct child and reproductive health services to approximately 120,000 persons in Matlab. The remaining portion  of the Matlab population is served by the health and family-planning programme of the Government of Bangladesh (GoB) and was the primary study area for this project.A demographic survey, based on a complete census of the study area, provided the sample for a household health and morbidity survey. The field work was carried out over six months from April to October 2000. The incidence of both diarrhoea and pneumonia varies seasonally in the survey area as in other parts of Bangladesh, and the survey period included a peak diarrhoea season. A sample of 2,200 under-five children was required for the survey to explain post-intervention changes of at least 20% in key family practices relating to child health between the IMCI and the comparison area with a power of 80%. Based on the initial numbers of under-five children identified in the demographic survey, we estimated that we would obtain the required number of children if we took a systematic sample of every 16th child found in the demographic survey. This sampling scheme also ensured that multiple children were not selected from the same household.http://www.who.int/imci-mce/Methods/household_survey.htm), was adapted for use in Bangladesh. The Principal Investigator translated it into Bangla, and it was then pretested for use in Matlab. The different sections were colour-coded to facilitate their use.The survey questionnaire collected information from the caretaker of the child on healthcare-seeking practices, illness in the previous two weeks, and care-seeking for those illness episodes. Data were also collected on home-care for illness and compliance with healthcare advice. Weight and height/length of the children were measured using the Uniscales  and locally-produced length/height boards. A generic questionnaire, developed by the World Health Organization/MCE team  adapted for use in Bangladesh. Specific illnesses investigated in this analysis included reported fever, diarrhoea, and probable pneumonia (defined as cough with rapid or difficult breathing which was not due to a blocked nose). The differences in illness and care-seeking rates were tested using the chi-square tests of independence/homogeneity. The exact tests were performed if group frequencies were small. We investigated about how rates of illness and care-seeking varied among those with different demographic, household, and illness characteristics. We also assessed associations of these variables for hospitalization rates, home management of illness and compliance with provider advice. Compliance was defined as adherence to the advice of the provider about follow-up, referral, and treatment of the child.The analysis was based on the standard MCE indicators and equity analysis guidelines .In total, 2,289 under-five children were sampled; of them, interviews were completed for 2,066 (90%). Five children had died since the demographic survey. The families of 142 children were not found at the time of the follow-up survey. The 142 lost-to-follow-up children did not differ from the 2,066 for whom interviews were completed in terms of wealth categories, but were more likely to be girls (63%) than the completed sample (48%); 69 children were no longer aged less than 60 months; and interviews were incomplete for seven children. The remainder of this analysis is based on the 2,066 children for whom interviews were completed.Characteristics of the sample of children are summarized in Table Table There were 114 hospitalizations in the previous year among the sampled children . Children whose illness was perceived to be severe tended to be more likely to receive increased fluids and continued feeding compared to mild-to-moderate episodes . Illness with at least one danger sign also appeared to be more likely to be treated with increased fluids and continued feeding compared to episodes with no danger signs . There were no differences in this aspect of home-care either by sex of the child or by the socioeconomic status level of the household.Table We also asked caretakers who had sought care from a trained provider whether the provider had asked that the child be brought back for a follow-up visit. If a follow-up visit had been recommended, we asked whether they had complied, or intended to comply, with the recommendation. A follow-up visit had been recommended for only 39 children (36%) who were taken to a trained provider. Within this group, 41% of caretakers reported that they had either complied or intended to comply with the recommendation (data not shown). None of the factors under investigation  was associated with the rate of compliance with follow-up, although small numbers make it impossible to have complete confidence in these results.This population-based sample survey provides new information about the morbidity patterns among Bangladeshi children and indicates that current rates of care-seeking and appropriate home-care must be improved in order for child mortality to continue to decline. Further analyses of these three intermediate outcomes by sex and age of the child, socioeconomic status of the household, and specific characteristics of the illness episode can help programme planners ensure that interventions reach all children who need them and inequities are minimized.The validity of the asset index for measuring socioeconomic status may be challenged. The index was created using exactly the same methodology used by the World Bank group  to invesAt 41%, the prevalence of underweight among the top 20% of households is high and not much lower than the national average (48%) .The results showed a very high prevalence of illness among Bangladeshi children. Over two-thirds of the children were reported to have been ill during the two weeks preceding the survey. We compared the rates of reported morbidities in this survey with those reported for rural Bangladesh by the BDHS 1999–2000 , althougAn important rationale for the development of the IMCI strategy was the belief that sick children often present with more than one symptom. This management of the child in a holistic approach has not been a strong point of disease-specific vertical programmes. Our data showed that most sick children in this population had multiple symptoms, suggesting that the use of the IMCI clinical management guidelines will lead to improved quality of care.Contrary to expectations, there were no significant differences in the prevalence of illness by sex or by socioeconomic status, although we did observe higher rates of perceived severe illness in boys which may be indicative of a bias in recognition of illness. The lack of a socioeconomic status difference needs to be treated with some caution because these were reported morbidities that can be affected by recognition of illness and adequacy of recall, both of which are likely to be better in higher socioeconomic status groups. These biases may have masked effects of socioeconomic status on the prevalence of illness.We were surprised by the low rates of hospitalization in our study population and by the lack of clear differences by economic status, despite a non-significant trend towards higher rates among those with more resources. It is possible that variations by economic status were not apparent because of small numbers, but the overall low rate of hospitalization is difficult to explain given that there are two hospitals serving the area, including one specialized diarrhoea hospital. Reports from other countries would lead us to expect higher rates of hospitalization . EvidencPoorer children were less likely to be taken to an appropriate healthcare provider than less-poor children, even in this apparently homogeneous and very poor rural Bangladeshi population. Our findings indicated that children with severe illness in the least poor households were three times more likely to seek care from a trained provider than children in the poorest households. Gwatkin and his colleagues found similar socioeconomic status differentials while analyzing data from the DHS 1996–1997 . Gender Although the Government of Bangladesh has an excellent public-health infrastructure—at least one primary care facility for population of 20,000 and a 31-bed hospital for 200,000 people—care-seeking for childhood illnesses, particularly from the formal health sector, was extremely low. About one-third of children with a reported illness did not receive any care outside the home. The majority of sick children for whom care was sought outside the home were taken to a village doctor. Only 8% went to a trained provider, i.e. a health facility, a hospital, a doctor, paramedic, or a community health worker. This rate of use of a trained provider is unexpectedly low. In the BDHS 1999–2000, 27% of children with probable pneumonia were taken to a health facility  of IMCI Effectiveness, Cost and Impact. This work could not have been done without the full cooperation of the families in the survey area. The authors appreciate their willingness to be interviewed, especially prior to the introduction of IMCI. The authors would also like to thank the MCE Central Team for their continued technical and administrative support to the study and the MCE Technical Advisors for important suggestions on earlier drafts of this paper and continued guidance through the course of the study.Finally, the authors deeply thank the partners in the Government of Bangladesh. The authors note their commitment to this study and for using the results of the research to improve child health plans and policies in Bangladesh.


Violence against women is now widely recognised as an important public health problem, owing to its health consequences. Violence against women among many Indian communities on a regularly basis goes unreported. The objective of this study is to report the prevalence and other related issues of various forms of domestic violence against women from the eastern zone of India.It is a population-based study covering both married women (n = 1718) and men (n = 1715) from three of the four states of Eastern India selected through a systematic multistage sampling strategy. Interviews were conducted using separate pre-piloted structured questionnaires for women (victimization) and men (perpetration). Women were asked whether their husband or any other family members committed violent acts against them. And men were asked whether they had ever perpetrated violent acts against their wives. Three principle domestic violence outcome variables  were determined by response to a set of questions for each variable. In addition, data on socio-economic characteristics were collected. Descriptive statistics, bi- and multivariate analyses were done.The overall prevalence of physical, psychological, sexual and any form of violence among women of Eastern India were 16%, 52%, 25% and 56% respectively. These rates reported by men were 22%, 59%, 17% and 59.5% respectively. Men reported higher prevalence of all forms of violence apart from sexual violence. Husbands were mostly responsible for violence in majority of cases and some women reported the involvement of husbands' parents. It is found that various acts of violence were continuing among majority of women who reported violence. Some socio-economic characteristics of women have significant association with the occurrence of domestic violence. Urban residence, older age, lower education and lower family income are associated with occurrence of domestic violence. Multivariate logistic regressions revealed that the physical violence has significant association with state, residence , age and occupation of women, and monthly family income. Similar associations are found for psychological violence  and sexual violence .The prevalence of domestic violence in Eastern India is relatively high compared to majority of information available from India and confirms that domestic violence is a universal phenomenon. The primary healthcare institutions in India should institutionalise the routine screening and treatment for violence related injuries and trauma. Also, these results provide vital information to assess the situation to develop public health interventions, and to sensitise the concerned agencies to implement the laws related to violence against women. Violence against women is widely recognised as an important public health problem, owing to its substantial consequences for women's physical, mental and reproductive health -5. This India possessed several communities which are distinct in their geography, language and culture. In several places of India, violence faced by women on a regularly basis goes unreported even in newspapers, where as newspapers often carry reports about young women being burnt alive or dying due to unnatural causes in unnatural circumstances . EstimatWe hypothesize that domestic violence is wide-spread phenomenon and variation in its prevalence occur across the eastern Indian states, as these states differ from each other in overall development. Also, it is hypothesized that differences occur within the population of these states based on some socio-economic characteristics such as habitation , age, religion/caste affiliation, education, occupation and income. The purpose of the present study is to report the prevalence of various forms of domestic violence against women and to examine various related issues from the eastern zone of India. The term domestic violence is usually taken to mean partner abuse, specifically violence perpetrated by male partner. However, it may also be used to refers to violence perpetrated by any member of the household towards the women . HoweverThe eastern zone of India possessed four states namely, Orissa, West Bengal, Bihar and Jharkhand. Of these four states, three states  were selected to have a wider representation of the zone. The population of these states was 31.7 million, 80.2 million and 26.9 million in the year 2001 ,28. The All the interviews were held in local language of the state. Interviews took place in a private place in or outside the respondents' home, and care has been taken to avoid presence of other family/community members during interviews. If some one comes nearer during interview, the discussion on general health was made and the interview was restarted after the third person has retired. Interviewers stressed that honest responses were needed during interview to gain insight into the issue. Participants were assured of the confidentiality of their responses. To attain all these, care has been taken to establish rapport with every participant prior to interviews. Women and men were interviewed by women and men investigators, respectively. Individual verbal informed consent was obtained from all participants by explaining the purpose of the study. These field works were carried out during September 2004–July 2005.The sample size was calculated based on the available estimated prevalence of domestic violence for these states . Based oAfter selecting the village/urban pocket, the research team met village/community heads and elders before initiating the data collection, and the purpose of the survey was explained. Rapport is established with the community and especially the women were taken to the confidence. The sample to be collected from each village was determined by dividing total rural sample required for that state by total number of villages (eight). In each village, eight random points were identified from all corners and care has been taken to include all communities. From each point, required number of sample was collected from households spread in four directions of the point. Similarly, in each urban pocket, participants were selected from the households spread in all the four directions. A married woman up to the age of 50 years of sampled household was sampled from each household. Corresponding to the women sample, married men aged below 50 years were selected in the similar way from the neighbouring village/urban pocket. Initially, 1753 women and 1730 men were contacted; however, 35 women and 15 men have refused to participate, yielding a refusal rate of 2% and 0.8% among women and men, respectively. Thus, samples of 1718 women and 1715 men were obtained.Three principle domestic violence outcome variables considered in our analysis are: physical violence, psychological violence and sexual violence. They were determined by response to a set of questions for each outcome variable. If a woman (as a victim)/man (as a perpetrator) gave a positive response to any of the questions in a set, it is considered as violence of that category. The questions used for women and men were listed in Annexure 1a and 1b, respectively in Additional file Data were collected on a number of community-level and individual-level variables that have been linked to domestic violence. The community-level variables included are the state of residence , residence , religion  and caste. During the survey, individual caste of the respondent was collected and they were categorized subsequently during analysis. The Government of India had categorised some ethnic groups (castes and tribes) into scheduled castes, scheduled tribes and backward castes, and these categories are entitled for positive discrimination in educational, employment and other developmental opportunities for their upliftment. The uncategorized castes, which form the majority of the population, are often referred to as forward castes. The individual-level variables were: age in years , education, which was categorized in to illiterate (those who can neither read nor write), functional literate , school education (1–10 years of schooling) and, college education and above (those having more than 10 years of education). The occupation of the participant was recorded and the responses were categorized into salaried jobs , farming and small business , labourer (daily-waged skilled and unskilled labourers), housewives (only women) and other occupations. The monthly income of the family was calculated during data analysis based on the information collected on income of all members as well as from common sources of the family. The income details were collected in Indian Rupees (INR). One INR was equivalent to 0.02 United States Dollars (US$). For logistic regression, these variables were used as categorical variables, except the age. The categories under each variable were explained above. The age was taken as continuous variable.p value of less than 0.05 was considered as the minimum level of significance.The data were computerized through Epi-Info 6. The database of Epi-Info was exported to SPSS and further analysis was carried out. The prevalence with 95% confidence intervals (CI) of different forms of domestic violence reported by women and men were computed for each of the states. For the domestic violence prevalence reported by women, the associations with socio-economic variables  were examined by using both bivariate and multivariate procedures. For each of the group under a variable, the prevalences in the form of percentages were presented and bivariate logistic regressions were carried out. In addition, multiple logistic regression analysis was used to model the presence or absence of physical, psychological and sexual violence, and any form of domestic violence by all of the aforementioned socio-economic variables. For these logistic regression analyses, the dependent variables were dichotomised (presence or absence of violence). The independent variables were categorised into different groups as described under measurements. While calculating odds ratios (OR), the category with the lowest weight was taken as the reference category. The OR is the value by which odds of the event (occurrence of violence) change when the independent variable increases by one unit/step. And it has been calculated by adjusting for all other independent variables in multivariate models. A The study protocol has been approved by the Human Ethical Committee of Regional Medical Research Centre. Individual informed consent was obtained from all participants, as mentioned above. Guidelines of World Health Organization, including the importance of ensuring confidentiality and privacy, both as means to protect the safety of study participants and field staff, and to improve the quality of the data were followed .The details of socio-economic characteristics of sampled women and men participants were presented in Table The prevalence of physical, psychological, sexual and any form of domestic violence in the life time of women were presented in Table Similarly, men were also interviewed to know whether they perpetrated any violence during their life time against their wives Table . The perIt was probed from the women about the person, who actually perpetrated different violent behaviour. Table It was probed to know whether or not the reported behaviours of violence are continuing currently among the women, who reported the experience of different acts of physical, psychological and sexual violence during their lifetime. If it is continuing, it was further probed for each act to know the periodicity of their occurrence. It is probed to know whether they are experiencing these acts daily. It is found that, almost all acts of violence were still continuing among majority of women Table . For exaTable The above associations were further examined through bivariate logistic regressions by taking presence or absence of violence as a dependent variable and women's socio-economic characteristic as a covariate (independent variables). OR along with levels of significance of regression models for all types of violence are shown in Table Further, multivariate logistic regressions were carried out to examine these associations, separately for each type of domestic violence Tables  and 10. In the present study, women reported as high as 56% of some form of violence against them in Eastern part of India. The levels of physical, psychological and sexual violence against women were also considerably high. These data along with the world-wide literature confirm that domestic violence is a universal phenomenon existing in all communities ,12,31. AThe present data demonstrated that in Eastern India, the domestic violence is persisting considerably across all socio-economic strata. Some characteristics of women namely, residence, age, education, occupation and family income have influence on the prevalence of domestic violence. The prevalence of violence decreased along with the increase of women's education and family income. However, no comprehensive studies are available from this part of India to compare these findings. One nation-wide study from India revealed that higher socio-economic status as a protective buffer against domestic violence . The datSome of the earlier studies from India revealed that though inadequate and failure of timely payment of dowry has been focused as an important reason for domestic violence in India, several other triggers of domestic violence such as negligence or failure in performing duties expected of women in the family also led to violence against women . These cThis study, along with the domestic violence rates based on the reporting of women, presented the prevalence of domestic violence reported by men, as perpetrator. These rates are in corroboration with those reported by women. Almost all research on domestic violence has relied on women's rather than men's report of their experiences . Few stuThere are limitations in this study, as usual to this type of research topic. The topic of interview is very sensitive and participants may not express their views openly, as they think that their responses may damage the reputation of themselves and their families. Sometimes in this type of research, participants may also report the behaviour that is believed to be consistent with their culture, rather than the actual . HoweverThe study confirms the high prevalence of all forms of violence against women across all socio-economic settings in eastern zone of India. However, urban residence, older age, lower education and lower family income are associated with occurrence of domestic violence. Women are at risk of violence from the husband than any other type of perpetrator. This situation has public health implications as public health can have a role in preventing the violence and its health consequences. Also, the primary healthcare institutions in India should institutionalise the routine screening and treatment for violence related injuries and trauma. These results also provide vital information to assess the situation to develop interventions as well as policies and programmes towards preventing violence against women. As India has already passed a bill against domestic violence, the present results on robustness of the problem will be useful to sensitise the concerned agencies to strictly implement the law.The authors declare that they have no competing interests.Both the authors contributed to the conception of the study design and development of study instruments. BVB involved in field works; coordinated in the data collection; computerized and analysed the data; interpreted the results; prepared the manuscript. Both the authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:Annexure 1. A: Questions posed to women in this study to consider physical, psychological and sexual violence against women. B: Questions posed to men in this study to consider physical, psychological and sexual violence against their wivesClick here for file


Using longitudinal data from three demographic surveillance systems (DSS) and a retrospective cohort study, we estimate levels and trends in the prevalence and incidence of orphanhood in South Africa, Tanzania, and Malawi in the period 1988–2004. The prevalence of maternal, paternal, and double orphans rose in all three populations. In South Africa—where the HIV epidemic started later, has been very severe, and has not yet stabilized—the incidence of orphanhood among children is double that of the other populations. The living arrangements of children vary considerably between the populations, particularly in relation to fathers. Patterns of marriage, migration, and adult mortality influence the living and care arrangements of orphans and non-orphans. DSS data provide new insights into the impact of adult mortality on children, challenging several widely held assumptions. For example, we find no evidence that the prevalence of child-headed households is significant or has increased in the three study areas. Most comparative studies of orphanhood and children's living arrangements in Africa have used data from cross-sectional surveys, including the Demographic and Health Surveys (DHS) and the UNICEF Multiple Indicator Cluster Surveys (MICS) . LongituThis section describes HIV prevalence and the emergence of the epidemic in the three study areas, and compares other demographic, social, and cultural characteristics influencing the living arrangements of children and households.The HIV epidemics in Malawi and Tanzania began earlier than in South Africa and, in a reference to the recent flattening out of HIV prevalence, have been described as ‘mature’ epidemics . PopulatAIDS is currently the leading cause of adult death in all study areas according to estimates based on verbal autopsies. The Karonga-DSS found that 60 per cent of men and 66 per cent of women aged 15–44 years who died in the period 2003–5 died from AIDS . AccordiPatterns of marriage, cohabitation of parents, and adult migration—important influences on children's living arrangements—differ between the study areas. Karonga has a higher rate of marriage than Kisesa, and rates in both are markedly higher than those in Hlabisa. The Karonga-DSS found that 81 per cent of women and 55 per cent of men aged 15–49 years were married in 2002 . In contrast, marriage rates are very low in South Africa, having declined substantially since the 1980s . The HlaAdult mobility is high in all three areas but is a defining characteristic of the Kisesa and Hlabisa populations. The Kisesa-DSS showed that, over the period 1994–98, approximately 11 per cent of adults aged 15–59 years migrated per year . In HlabDetailed descriptions of the study areas and methods are presented elsewhere . For claThe Africa Centre Demographic Information System (ACDIS) is located in the Umkhanyakude district in northern KwaZulu-Natal, South Africa. Started in 2000, ACDIS has a surveillance population that comprises approximately 89,000 members in 11,000 households. Household updates are conducted twice a year .The Karonga Prevention Study (KPS) has conducted several community-based studies in the Karonga district of northern Malawi. Two population surveys were conducted in the 1980s , and a rThe Kisesa Open Cohort is a DSS located in the Magu district in the Mwanza region in north-west Tanzania. Half-yearly demographic surveillance updates were started in 1994 for a population of approximately 20,000 people living in 4,600 households , which hSeveral methodological issues need to be considered in the analysis and interpretation of longitudinal data on orphans.In these three DSSs, the survival status of a child's parent can be established in two ways. First, it can be established through routine prospective observations of the child and its linked parent when both are registered individuals in the DSS. Many children are linked to their parents from the time they are registered as new births in the surveillance area. In the Kisesa-DSS, 78 per cent of all children under 18 years of age can be linked to their mothers and 56 per cent to their fathers. In the Hlabisa-DSS, the proportions linked are 78 and 42 per cent, respectively, and in the Karonga-DSS, 92 and 81 per cent. The second way of linking parent and child uses data from a direct question about whether a child's parent is alive. This ‘orphanhood’ question was asked of every child in the Kisesa-DSS during the baseline census in 1994, and again in the 2000 and 2004 rounds. In the Hlabisa-DSS orphanhood data are collected directly when a child is registered and (since 2004) at every household update visit. On the other hand, the Karonga-DSS collected orphanhood data directly in the baseline census and subsequently when new children were registered.There is a variety of definitions of maternal, paternal, and double orphanhood. We use the UNAIDS definitions: maternal orphans are children whose mothers have died and whose father is alive or whose survival status is unknown, while paternal orphans have the opposite characteristics. Double orphans are those who have lost both parents .In Malawi and Tanzania, relatively few children enrol in secondary school and the median age of marriage for women is around 18 years. In contrast, the majority of children in South Africa will still be in full-time education at age 18 years, and 18 is the minimum legal age of marriage. In order to avoid distorting comparisons of children's living arrangements by including people who started or joined other households following marriage, an upper age limit of under 15 years is used for the Kisesa-DSS and the Karonga-DSS and under 18 years for the Hlabisa-DSS .The criteria used to define a household in each study area are important when comparing data on living arrangements. While in all areas investigators rely on respondents to identify the members of their household, only resident household members are eligible for registration and follow-up in the Karonga-DSS and Kisesa-DSS . Follow-By the end of the 1990s, the prevalence of maternal orphanhood in all study areas was similar (2–3 per cent among under-15s). In Karonga, the proportions of orphans of all types increased between the end of the 1980s and 2004, with the largest increase occurring in the proportion of paternal orphans. The proportion of maternal orphans found by the Hlabisa-DSS also doubled, but since the level of paternal orphanhood was already very high by 2000 the increase seemed less dramatic over the subsequent few years. The increase in orphanhood prevalence found in the Kisesa-DSS was lower than that found in the other areas, probably because of the lower HIV prevalence. In 1999, national HIV prevalence in Tanzania (8 per cent) was half that of Malawi in 2000 (16 per cent). The most recent estimates of paternal orphanhood are high in all study areas. In Kisesa and Hlabisa a quarter of all children in the age group 15–17 years lost a father. However, the level of double orphans in Hlabisa is not as high as in the other two areas, suggesting that high rates of non-AIDS mortality in men may account for much of this excess mortality among fathers. The national DHS estimates in the year closest to that for which the DSS estimates are made are similar to the DSS estimates.Orphanhood incidence can be calculated using the longitudinal DSS data. Incidence is calculated as the number of maternal deaths  per 1,000 person-years among children in each age group whose mother was living at the start of follow-up. For children whose parent died, the exposure period is calculated as the period between the start of follow-up and the date the parent died. For children who out-migrated, ceased to be a member of the household, or died, the years of follow-up are censored at the point that observations of the child stopped. Incidence rates and confidence intervals were calculated using Poisson regression. There are marked differences between the three sites in the living arrangements of both non-orphans and orphans . Accordichildheaded household’.The relationship of each member to the head of the household is the only variable that can be used to compare the patterns of intra-household relationships . The KarThe DSS data show increasing orphanhood prevalence in the three populations over the last decade. The prevalence of paternal orphanhood is substantially higher than that of maternal orphanhood in all populations, partly because fathers are on average older than mothers but also in part because of age and sex differentials in HIV infection and survival times. The orphanhood prevalence found by the three DSSs are consistent with findings based on DHS data reported in other comparative studies of orphanhood . The KarThe living arrangements of orphaned and non-orphaned children vary considerably between the three populations. In Karonga and Kisesa, the majority of non-orphans live with both parents, 86 and 66 per cent, respectively, a pattern that contrasts markedly with that found in Hlabisa, where only 27 per cent of non-orphans live with both parents. These differences cannot be attributed solely to labour migration. Variations in patterns of cohabitation, extra-marital fertility, and union stability are even more important than migration as influences on whether a child's parents live together. Like In Karonga and Kisesa the long-term responsibility for fostering older children is usually undertaken by an aunt, uncle, or older sibling. Children cared for by relatives will in most cases have joined a new household on being fostered. In Hlabisa, however, almost half of all non-orphans live in a household headed by their grandparent, a finding that reflects the well-established South African tradition of grandparents rearing their grandchildren whether or not the child's parents are alive , 1993.We found no evidence in any of the populations that increases in orphanhood prevalence had led to a substantial increase in the number of child-headed households. In Karonga and Kisesa, no child-headed households were identified and fewer than ten were found in Hlabisa. This finding raises questions about the appropriateness of the prominence given to these households in HIV impact studies and programmes for children affected by HIV and AIDS .In the study of orphanhood, a DSS has several advantages over cross-sectional surveys. Repeated visits to households by fieldworkers can identify children living in them without their parents (such as children who work for the household) who might be overlooked in a single visit. The adoption effect, a potential source of bias in surveys, may also be minimized through repeated household visits and prospective record linkage .This was the first comparative family demography study to use data from several DSSs. By showing the problems of extracting comparable indicators of orphanhood and intra-household relationships, it has highlighted challenges that arise in analysing comparative data from these sources. While many DSSs collect information on living arrangements, each was designed independently to support different research agendas. Even direct comparisons of core demographic data are constrained by differences in variables, definitions, and coding. We hope that comparative exercises like the one presented here will promote the collection of data that could extend possibilities for comparative work. For example, it might encourage organizers of DSSs to identify biological fathers and to ask direct questions about parental survival.The levels of and trends in orphanhood prevalence in these three study areas are worrying evidence of the impact that the HIV epidemic is having on the lives of children and families in Africa. The high incidence of orphanhood shows that without effective and accessible interventions to reduce parental mortality, the proportion of orphaned children will continue to rise. Government programmes to provide antiretroviral therapy have started in all three populations, but in the early years of these programmes they are unlikely to reduce adult mortality sufficiently to avoid further increases in the overall prevalence of orphanhood.DSS data have been largely under-utilized in studies of social change and its impact on children in Africa. They are a potentially useful source of contextual information that can inform the design of programmes directed at children and their households, especially if they collect data on orphans and vulnerable children. While the generalizability of a single DSS's findings are inevitably constrained by the fact that its data are collected from people living in one small area, the potential for contributing to effective policy can be greatly improved if the findings are replicated in several areas. This point is well illustrated by the fact that we found scarcely any child-headed households in the three areas compared in our study.


Time to Change Cambridge anti-stigma campaign as an example.In view of the high costs of mass-media campaigns, it is important to understand whether it is possible for a media campaign to have significant population effects over a short period of time. This paper explores this question specifically in reference to stigma and discrimination against people with mental health problems using the 410 face-to-face interviews were performed pre, during and post campaign activity to assess campaign awareness and mental health-related knowledge, attitudes and behaviours.If a friend had a mental health problem, I know what advice to give them to get professional help, following the campaign. Additionally, for the statement: Medication can be an effective treatment for people with mental health problems, there was a 10% rise (p = 0.05) in the proportion of interviewees responding 'agree' or 'strongly agree' following the campaign. These changes, however, were not evident for attitudinal or behaviour related questions.Although campaign awareness was not sustained following campaign activity, significant and sustained shifts occurred for mental health-related knowledge items. Specifically, there was a 24% (p < 0.001) increase in persons agreeing with the statement: Although these results only reflect the impact of one small scale campaign, these preliminary findings suggest several considerations for mass-media campaign development and evaluation strategies such as: (1) Aiming to influence outcomes pertaining to knowledge in the short term; (2) Planning realistic and targeted outcomes over the short, medium and long term during sustained campaigns; and (3) Monitoring indirect campaign effects such as social discourse or other social networking/contact in the evaluation. Time to Change launched a national social marketing campaign aiming to reduce stigma and discrimination against people with mental health problems). The MAKS includes 6 items which assess stigma-related mental health knowledge. Overall test-retest reliability of the MAKS is 0.71 and the overall internal consistency among items is 0.65. However, since the MAKS was not developed to function as a scale the internal consistency value is less important . AttitudOverall, low to moderate levels of campaign awareness were reached. Shifts in the proportion of people reporting any campaign awareness, however, changed rapidly. Our evaluation showed that prompted campaign awareness increased incrementally over the 4-week period of the campaign and peaked during the last week of the campaign at 23%. Campaign awareness, however, fell sharply to 6% two weeks following the campaign. Notably, campaign awareness was 5% before the campaign began, indicating no change in prompted campaign awareness before and after campaign activity.If a friend had a mental health problem, I know what advice to give them to get professional help, following the campaign. Additionally, for the statement: Medication can be an effective treatment for people with mental health problems, there was a 10% rise  in the proportion of interviewees responding 'agree' or 'strongly agree' following the campaign  increase in persons agreeing slightly or strongly with the statement: Although these results only reflect the impact of one small scale campaign, these preliminary findings suggest several considerations for mass-media campaign development and evaluation strategies. First, the data suggest that it may be easier to influence outcomes pertaining to knowledge in the short term rather than aiming to influence attitudes or behaviour. Although there may be more extensive barriers to shifting attitude or behavioural outcomes, changing knowledge around what people can do is an important outcome in itself. Much has been written as to whether improved knowledge is a useful outcome and whether public education itself is sufficient or even useful . AlthougTime to Change Cambridge campaign, this difference exists because the campaign messages are easier to recall than actual campaign activity. Alternatively, it is possible that the campaign works indirectly to influence stigma and discrimination at the population level. For instance, one of the aims of Time to Change was to promote discussion about mental health problems facilitated by "talking points" around the town which included public sofas and publicity in pubs and cafes. These points were designed to facilitate discussion about or disclosure of mental health problems. Although many individuals may not have come into contact with the campaign and therefore could not recall actual campaign activity, it is possible that they were influenced by individuals who were campaign aware and who discussed the campaign messages with them. Individuals for which the campaign was more salient  may have been motivated to champion the cause following the campaign. These 'champions' may have discussed or shared campaign messages with others who were not campaign aware. Given the significance of social contact in other studies [The disparity between sustained campaign awareness and sustained changes in other campaign outcomes is informative when thinking about campaign evaluation and for exploring the mechanism of action of population level change. For instance, it is possible that in the case of the  studies ,19, mediWhile this study contributes new and important information which may inform the planning of future media campaigns, there are limitations which should be considered. Although the sample was weighted to be representative of the target population in Cambridge in terms of gender, age, and socioeconomic group, the participants were only a sample of Cambridge and may not represent the entire target population in Cambridge. Additionally, although the study used quotas to ensure equality of the target characteristics , different individuals were interviewed at each time point. Although this reduces the potential of an effect resulting from repeating the interview, we cannot be sure that differences in attitudes were not due to sampling characteristics. Finally, although the study included 50% of confirmed press readers to allow participants a greater opportunity to see the campaign and hence examine the relationship between awareness and attitude change, we cannot extrapolate the awareness figures to the entire population.Our evaluation demonstrated the potential of short term campaigns for achieving positive mental health-related knowledge outcomes of the type that have been shown to positively influence stigma related outcomes following a 4-week mass-media campaign. This is in line with social marketing literature which advocates targeting small and incremental changes in outcomes over an extended period of time  and healTime to Change is England's most ambitious programme to end the discrimination faced by people with mental health problems, and improve the nation's wellbeing. Mind and Rethink are leading the programme, funded £16 m from the Big Lottery Fund and £4 m from Comic Relief and evaluated by the Institute of Psychiatry at King's College, London. GT has received grants for research purposes for stigma related research in the last 5 years from Lundbeck UK and from the National Institute for Health Research, and has acted as a consultant to the UK Office of the Chief Scientist.SEL participated in the conception and design of the study, analysis of data, drafting the article and revising it critically for important intellectual content, and final approval of the version to be published.JL participated in the acquisition of data, drafting the article or revising it critically for important intellectual content, and final approval of the version to be published.KL participated in the conception and design of the study, drafting the article or revising it critically for important intellectual content, and final approval of the version to be published.CH participated in the interpretation of the data, drafting the article or revising it critically for important intellectual content, and final approval of the version to be published.GT participated in the conception and design of the study, drafting the article or revising it critically for important intellectual content, and final approval of the version to be published.SEL and KL are postdoctoral researchers and JL is a researcher in the Health Service and Population Research Department at the Institute of Psychiatry, King's College London. CH is a Senior Lecturer in the Health Service and Population Research Department at the Institute of Psychiatry, King's College London. GT is Professor of Community Psychiatry and Head of the Health Service and Population Research Department at the Institute of Psychiatry, King's College London. He is a Consultant Psychiatrist and Director of Research and Development at the South London and Maudsley NHS Foundation Trust.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/339/prepub


In Japan, as in many other countries, several quality and safety assurance measures have been implemented since the 1990's. This has occurred in spite of cost containment efforts. Although government and hospital decision-makers demand comprehensive analysis of these activities at the hospital-wide level, there have been few studies that actually quantify them. Therefore, the aims of this study were to measure hospital-wide activities for patient safety and infection control through a systematic framework, and to identify the incremental volume of these activities implemented over the last five years.Using the conceptual framework of incremental activity corresponding to incremental cost, we defined the scope of patient safety and infection control activities. We then drafted a questionnaire to analyze these realms. After implementing the questionnaire, we conducted several in-person interviews with managers and other staff in charge of patient safety and infection control in seven acute care teaching hospitals in Japan.At most hospitals, nurses and clerical employees acted as the main figures in patient safety practices. The annual amount of activity ranged from 14,557 to 72,996 person-hours  across participant hospitals. Pharmacists performed more incremental activities than their proportional share. With respect to infection control activities, the annual volume ranged from 3,015 to 12,196 person-hours . For infection control, medical doctors and nurses tended to perform somewhat more of the duties relative to their share.We developed a systematic framework to quantify hospital-wide activities for patient safety and infection control. We also assessed the incremental volume of these activities in Japanese hospitals under the reimbursement containment policy. Government and hospital decision makers can benefit from this type of analytic framework and its empirical findings. Recently in Japan, as in many other countries, several quality and safety assurance activities have been executed through either voluntary actions on the part of individual hospitals, external policy, or legislative pressures . This reDespite these important developments, there have been few studies aimed at comprehensively analyzing these activities at the hospital level. A primary reason for this has been the difficulty in defining which activities are part of routine medical care and which are specifically part of patient safety and infection control practices. There are two reasons it is critical for a comprehensive methodology to be developed to frame this issue. One is that it is important for both hospitals and policymakers to be able to use a standardized system to evaluate these activities over time across hospitals. Second, a standard measurement framework is central to any analysis of the potential costs and benefits of patient safety practices. These considerations are especially true in Japan, where hospitals typically underutilize critical patient safety practices.The aims of this study were to measure hospital-wide activities for patient safety and infection control through a systematic framework, and to identify the incremental volume of these activities implemented over the last five years.To define the scope of patient safety and infection control practices, we used the concept of incremental activity corresponding to incremental cost. Namely, the incremental activity was defined as the additional patient safety and infection control provided in a hospital in the current year compared to typical activity levels in 1999 (the base case). In other words, we assessed patient safety and quality assurance activities that have been introduced or strengthened since 1999. This approach was used because major developments in patient safety and quality assurance have taken place in Japan since 1999. Although medical advances have also occurred during that time, basic patient care practices have not significantly changed relative to patient safety and infection control. Interest in patient safety practices increased markedly in 1999 following highly publicized medical accidents. These accidents resulted in an analysis of the topic published by the Ministry of Health, Labor and Welfare . This reEach participating hospital was a certified teaching hospital with more than 300 beds, played a central regional role and provided emergency and intensive care services. Each hospital made strong efforts for patient safety and quality assurance. They were located throughout the country and the ownerships of them were various, including public sector, healthcare corporations, and company. We obtained informed consent from each participating hospital.This study was approved by the Institutional Review Board of the Faculty of Medicine at the Graduate School of Medicine of Kyoto University (reference number E-5). This survey was conducted from Aug 2005 to Mar 2006.To develop a framework that measures hospital-wide activity for patient safety and infection control, we reviewed findings from past international studies -11 and iBased on this framework, we developed questionnaire items. For staff assignment, we calculated the amount of time spent working on each specific activity by profession type. Additionally, we gathered activity contents, numbers classified by profession , the activity time per year, and the frequency of each activity. This data was used to calculate the annual activity in terms of person-time in 2004. For example, in the case of a supreme decision-making board committee on patient safety, we asked how many people belonged to the committee, which specialties the members belonged to, how many hours were spent for the functioning of the committee, and how many times the committee met during 2004. Each activity studied had been introduced or strengthened since 1999, specifically for the purpose of patient safety and quality assurance.We conducted a self-administered questionnaire and several in-person interviews with the managers of divisions in charge of patient safety and infection control in seven acute care teaching hospitals. In most cases, because responsibilities for patient safety and for infection control were separate, we administered separate questionnaires to the staff and managers of these divisions. We also asked about a variety of staff duties at key locations such as nursing sections, pharmaceutical sections, and administrative sections to participate in this survey, according to need. In order to partially control for differences in the definitions and scope of activities between hospitals, we sent the list of all the collected activity contents to each hospital and requested each to report whether the hospital offered information of all the executing activities.Table Table With respect to infection control, the activity volume ranged from 3,015 to 12,196 person-hours across participant hospitals. This volume was relatively less than that used for patient safety. The mean volumes per 100 beds and per 100 staff were 1,141 person-hours and 613 person-hours, respectively. The most common activity varied by hospital; in three hospitals it was education and in one hospital it was internal review and walk rounds.Figure In this study, we developed a framework for analyzing hospital-wide activity for patient safety and infection control. We systematically measured the volume of activity in seven Japanese hospitals using a developed framework. In the organization of patient safety activities, nurses and clerical employees typically formed the bulk of the staff. In the infection control division, medical doctors and nurses tended to be more often assigned. However, even if the total staff count was calculated by adding all professions' FTE, the ratio of most assigned hospitals remained about one FTE per 315 beds at best. This is lower than other studies, which reported values such as three FTE ICPs per 500 beds one per 167 beds) , one per7 beds , There are several important features of our study. First, we introduced the concept of incremental activity, corresponding to incremental cost, into the extraction of the activity of patient safety and infection control. Using this definition, the scope of activities was specified, and we were able to extract more useful information. This was also made possible by utilizing a unique Japanese context; 1999 was a watershed year in the development of patient safety and infection control practices. This gave a base year for the incremental assessment. Second, we obtained useful information for many hospitals that have yet to develop patient safety and infection control practices. As mentioned above, there are few hospitals performing these activities vigorously, and there is little information available about them in Japan. As such, this study opens the possibility for hospitals to learn from others with respect to patient safety and infection control practices. Finally, we also obtained potentially useful information for improving the reimbursement system and reallocating resources for the sustainability of quality healthcare delivery. Recently, the volume of patient safety and infection control activities remarkably increased, but the costs of these activities are not yet covered in the current payment system. Thus, the systematic and empirical findings presented here will be useful for the establishment of a safe and durable system of healthcare delivery.Some limitations must be considered when interpreting the results of our study. First, hospitals selected in this study may not be representative of hospitals performing vigorous patient safety and infection control practices in Japan. In selecting participant hospitals, we utilized reputation, public relationship descriptions on their homepage, and magazine and newspaper articles. This was an attempt to ensure that participant hospitals would be among the most likely to have implemented the most rigorous practices. This was impossible to validate, however. Second, we could not get information on the activities performed by small groups, such as activity at the ward level. However, the aim of this study was to understand hospital-wide activities. Given time and financial limitations, the approach taken here was the most effective at achieving this objective.Future studies are needed to further develop this framework in order to estimate the contribution of information technology systems, such as ordering systems and electronic medical charts. Since patient safety activities can be supplemented with information technology -18, it iIn this study, we developed a systematic framework to quantify hospital-wide activities for patient safety and infection control. We assessed the incremental volume of these activities in Japanese hospitals under the reimbursement containment policy. The government, as well as hospital decision makers that must understand resource allocation for patient safety and infection control activities, can benefit from this analytic framework and its empirical findings.The author(s) declare that they have no competing interests.YI conceived of the research. KH and HF collected the data and performed data analysis. KH wrote the first draft of the manuscript. All authors read, jointly revised and approved the final version of the manuscript.The pre-publication history for this paper can be accessed here: