Well-trained and highly motivated community health workers (CHWs) are critical for delivery of many community-based newborn care interventions. High rates of CHW attrition undermine programme effectiveness and potential for implementation at scale. We investigated reasons for high rates of CHW attrition in Sylhet District in north-eastern Bangladesh.Sixty-nine semi-structured questionnaires were administered to CHWs currently working with the project, as well as to those who had left. Process documentation was also carried out to identify project strengths and weaknesses, which included in-depth interviews, focus group discussions, review of project records (i.e. recruitment and resignation), and informal discussion with key project personnel.Motivation for becoming a CHW appeared to stem primarily from the desire for self-development, to improve community health, and for utilization of free time. The most common factors cited for continuing as a CHW were financial incentive, feeling needed by the community, and the value of the CHW position in securing future career advancement. Factors contributing to attrition included heavy workload, night visits, working outside of one's home area, familial opposition and dissatisfaction with pay.The framework presented illustrates the decision making process women go through when deciding to become, or continue as, a CHW. Factors such as job satisfaction, community valuation of CHW work, and fulfilment of pre-hire expectations all need to be addressed systematically by programs to reduce rates of CHW attrition. Community Health Workers (CHWs) can increase access to, and use of, health services, and have played a part in primary health care, tuberculosis, immunization and family planning programmes. CHWs received less attention in the 1990s, but now again are at the centre of discussions about how to improve coverage and equity, particularly in populations with limited access to health facilities .CHWs have been promoted for implementation of packages of interventions to reduce neonatal mortality such as antenatal home visits, promotion of immediate and exclusive breastfeeding, skin-to-skin care, appropriate care of the skin and umbilical stump -6, and rSyed and colleagues found that CHWs were effective in tracking pregnant women through the postnatal period and in raising awareness of appropriate maternal and newborn care practices . ImplemeThe term 'community health workers' can refer to a variety of health care providers such as village health workers, community resource people, traditional birth attendants or workers known by local names. While these providers are trained, they typically do not have any professional certification . CHWs caHaines and colleagues propose four determinants of the success of a CHW programme: 1) national socioeconomic and political factors, including corruption and political will; 2) community factors such as location and infrastructure and health beliefs; 3) health system factors such as remuneration and supervision, and 4) international factors including migration flow and technical assistance ,1. All oIn addition to the factors listed above, individual CHW motivation impacts retention and attrition. Motivation is driven by many elements including intrinsic factors such as an individual's work-related goals, as well as his/her sense of altruism, self-efficacy, and organizational commitment. Extrinsic factors include peer approval, the incentives provided, and the expectation of future paid employment -18. ThesSignificant rates of attrition undermine programmes' investments in CHWs, and potentially limit the effectiveness of community-based interventions aimed at reducing neonatal mortality. Higher attrition rates are associated with volunteers . One revHenderson and Tulloch identified a number of key recommendations for retaining salaried health-workers . RecommeA newborn care intervention trial ("Projahnmo-1"), conducted in Sylhet District in north-eastern Bangladesh, evaluated the effectiveness of two different service delivery models of a package of maternal and newborn care interventions ,26,9,10.CHWs were offered a remuneration package of 3200 Bangladeshi taka per month, which is equivalent to US$ 45 dollars. They were expected to work from eight in the morning to four in the afternoon six days a week, with newborn care visits to be made within the first day of life, even if that meant visiting the household on a holiday. Their work also involved paying informal unscheduled visits to households when and if families needed their assistance, especially when attending a sick neonate. The remuneration package did not include a scheduled incremental increase. Therefore, though it was comparable to that of other similar governmental job opportunities in the beginning (i.e. working as a Family Welfare Assistant or FWA), after a year there was a marked difference between their salary and that of the government FWAs.In implementation of the Home Care intervention arm, CHW attrition was identified early on as a significant constraint on the effectiveness of the intervention package. This paper explores the causes of attrition, as well as how CHW attrition was analyzed and addressed by this community-based newborn care intervention in rural Bangladesh.Sylhet is known to be a relatively conservative region of Bangladesh. Recruiting women for a CHW position, a type of work unfamiliar to the community, proved to be difficult at first. Initially the Sylhet project planned to recruit married women with 10 or more years of education to serve as CHWs. The educational requirement was necessary because of the detailed record forms CHWs had to complete as part of the study. Due to the shortage of married women with the requisite educational background, along with the initial reluctance of women to serve as CHWs in general, the project ultimately recruited single women.A total of 41 CHWs were recruited at the beginning of the intervention in Sylhet District who fulfilled the following criteria:1) female,2) local resident in the area of assignment,3) preferably married (this criterion was dropped when it proved impossible to identify sufficient numbers of eligible married women),4) aged between 20 and 40, and5) secondary school leaving certificate (SSC pass).Initially there were 38 CHW service areas (areas covered by one CHW), thus three CHWs were available to serve as replacements in the event of attrition among the other 38 CHWs. In the early months of the project, two service areas were deemed too large for effective coverage by 1 CHW, and were subsequently divided, ultimately resulting in 40 CHW service areas.CHWs were recruited through advertisements placed in a local newspaper. Candidates meeting the criteria sat for a written general knowledge examination that covered questions such as: "What are the main child health problems in Bangladesh?" and "What is an NGO?". Candidates who passed the written examination were interviewed at the project office. If they passed the interview and agreed to work they then received six weeks of training. After training they were evaluated on maternal and newborn care knowledge and relevant skills for intervention.Initial CHW responsibilities included visiting assigned households to identify pregnant women (pregnancy surveillance). Subsequently, CHWs began providing registered pregnant women with birth preparedness messages and materials. Attending deliveries, attending sick newborns, referral of women and newborns to care, and, in the case of referral failure, treatment of sick newborns in the home with injectable antibiotics , as wellOver the course of the four-year project, a total of 73 CHWs were recruited either initially (41 CHWs) or later on to replace CHWs who left the project, requiring additional efforts by the programme to recruit and train replacement CHWs. The total period of intervention was 36 months. Thirty-two CHWs (referred to as former CHWs in this paper) left the project during this period, of whom 15 left within one year, and another 10 by the end of the second year of the project. Training of the replacement CHWs had a higher unit cost, because they were trained on an on-going basis, sometimes only a few at a time. Dedicated trainers were initially recruited for the project only on a short-term basis, thus the responsibility for training new CHWs fell to the supervisors in the later phase of the project. This proved extremely difficult, given their routine programme responsibilities. The project took the following steps in order to address the problem:• Project staff, including senior level managers, visited the houses of CHWs and talked with their parents and guardians, communicating the aims and activities of the programme and emphasizing the benefits to the community as well as to their daughter/s.• From the outset of the project, staff of the implementing non-governmental organization partner (Shimantik) held community advocacy meetings to explain the project and respond to community concerns. The NGO added a new step of initiating dialogue with the parents and guardians of the new CHWs at the time of recruitment in order to explain the project and roles of the staff members.• A number of field-level workers were given the opportunity to become supervisors based on exemplary performance.• A number of incentives were created, such as incentives for the CHWs to attend deliveries at night.Data from three different sources are presented. The first source is employment records of CHWs in the newborn care intervention trial in Sylhet District , with meall CHWs, both those who had left and those still working for the project. CHWs were given complete freedom to respond as they saw fit. CHWs were given the confidence and assurance that their names would be removed at the time of analysis of the data. Data were further strengthened by informal discussions with field managers and supervisors aimed at gaining insight from their field experiences. Finally, data are included from a complementary qualitative process documentation exercise consisting of in-depth interviews, focus group discussions, a review of project records (i.e. recruitment and resignation), and informal discussion with key project personnel.The second source of data is a survey of factors affecting retention and attrition administered to 69 of the 73 current and former CHWs in Sylhet District. Semi-structured questionnaires were administered in 2005 to CHWs currently employed and those who left the job in order to elicit information on job satisfaction, demands, and aspirations. This was a self-administered questionnaire in which, after a brief explanation of how the questionnaire was arranged, respondents were asked to complete it based on their interpretation. The self-administered questionnaire for CHWs had 45 questions, divided into four parts: 1) Personal and family history, 2) Motivation behind CHW work, 3) Experiences related to CHW work, and 4) Reasons for leaving. There were both multiple-choice and open-ended questions. A mid-level manager who was not directly supervising the CHWs was chosen as the facilitator for the self-administered questionnaires. The respondents were Table Rates of CHW attrition were far higher in Sylhet than in Tangail over the 36-month period of the two projects (2004-2006). In Sylhet 52.5% of the 40 CHW service areas had the same CHW from the beginning to end of the project Table , compareTables Table Data on CHW retention were also collected from a process documentation exercise carried out mid-way through the project at the Sylhet site. Respondents were asked why they became CHWs, and the majority explained that they wanted to help improve newborn and maternal health in their community. Beyond the benefits of employment, many CHWs anticipated that the position would positively impact their families and neighbours, as well as their own personal lives. For many of these women, "work is good; whatever it is. Joblessness is a curse." For most CHWs, this was their first job, and many considered it to be a gateway to future work. Two of the CHWs explained:"Initially it was only money, but later I figured that this job may help me in the future to get better jobs. Maybe someday I will be able to become a paramedic.""If I get another job, be it a government job or not, I would like it to be related to health, since I know a lot about health now."The ability to make financial contributions to the family is a substantial impetus in CHW retention, despite concerns about the heavy workload and discomfort with the evening and holiday travel required by the job.Many CHWs expressed interest in pursuing future employment as another type of health care provider and doing work such as delivering babies, becoming a paramedic, or working for the government as a community or facility-based health worker. A few hoped to work as a government school-teacher. Additional motivating factors included meeting other women with similar interests and goals. Several CHWs expressed desires of independence and the ability to help provide financially for their families: for their husbands and children (for those who were married) and for their siblings (for those who were unmarried). Despite attempts at saving money, CHWs reported difficulty especially in the few cases where CHWs were recruited outside their cluster areas and thus were required to pay rent by their jobs.In-depth qualitative interviews suggest that CHWs would recommend CHW work to a relative or friend, as long as all the relevant aspects of the job were explained in advance. Women said that they would stress the importance of CHW work in reducing neonatal mortality in the community, the opportunity for the CHW to expand her knowledge of health-related matters, and the benefit of having a monthly salary. Two CHWs felt that the role of CHW increased women's independence and marketability for better-paying jobs, although concerns were raised about the response of the community and overall handling of the workload:"I would recommend the CHW job, but I will let them know everything, including how hard it is. I would also warn them of problems with not being paid travel bills regularly. If she likes what I say, then she will go ahead and work."Table Most current and former CHWs noted in in-depth interviews that movement throughout all parts of the community was a problem, both for them and for their families. Some of the CHWs commented that they were initially very reluctant to move around and were referred to as 'girls' by community members. In the local Sylheti language, "phuri" meaning girl is used for any unmarried woman, rather than "mohila" meaning woman. The project CHWs were referred to as "phuri" because they were unmarried.niqab). Now they feel more confident and move around alone, taking the bus or any other vehicle to travel to distant villages.Current CHWs reported, however, that much of the initial discomfort and apprehension had dissipated since many of them began wearing a Muslim headdress • Hardship allowances can be provided to ensure newborn visits during holidays and beyond official work-hours. (factor # 1)• Sick leaves can be provided for unforeseen sicknesses and medical emergencies. • In response to families' concerns regarding their daughter's CHW responsibilities, group discussions can be arranged to engage the family in particular and the community as a whole to increase the sense of ownership of the project. This can be an effective community mobilization tool. (factor # 4)• At the planning and training stage of a project, it should be ensured that the expectations of CHWs regarding their roles and responsibilities are clear and that they do not evolve into different roles and responsibilities over time. There should be frank discussions of less pleasant aspects of the job, such as late hours and holiday duties, so that they are fully aware of what to expect. (factor # 5)These five factors will impact each CHW differently. As she weighs the factors and their impact on her own life, she will decide whether the benefits of being a CHW outweigh the costs. The framework shows that at this point in the decision-making process, there is an opportunity for the CHW and the project to negotiate to increase the benefits of employment and/or reduce the costs to the CHW. Finally, the CHW will consider the five factors and the results of any negotiation with the project and determine whether she will continue to work as a CHW.The authors declare that they have no competing interests.All authors read and approved the final manuscript.


Patient information, medical history, clinical outcomes and demographic information, can be registered in different ways in registration programs. For evaluation of diabetes care, data can easily be extracted from a structured registration program (SRP). The usability of data from this source depends on the agreement of this data with that of the usual data registration in the electronic medical record (EMR).Aim of the study was to determine the comparability of data from an EMR and from an SRP, to determine whether the use of SRP data for quality assessment is justified in general practice.We obtained 196 records of diabetes mellitus patients in a sample of general practices in the Netherlands. We compared the agreement between the two programs in terms of laboratory and non-laboratory parameters. Agreement was determined by defining accordance between the programs in absent and present registrations, accordance between values of registrations, and whether the differences found in values were also a clinically relevant difference.No differences were found in the occurrence of registration (absent/present) in the SRP and EMR for all the laboratory parameters. Smoking behaviour, weight and eye examination were registered significantly more often in the SRP than in the EMR. In the EMR, blood pressure was registered significantly more often than in the SRP. Data registered in the EMR and in the SRP had a similar clinical meaning for all parameters (laboratory and non-laboratory).Laboratory parameters showed good agreement and non-laboratory acceptable agreement of the SRP with the EMR. Data from a structured registration program can be used validly for research purposes and quality assessment in general practice. In general practice the use of electronic medical records (EMRs) instead of paper patient records has become more and more common -5. In anUse of EMRs can not only improve care management, but can also be beneficial for research -11. DataA structured registration program (SRP) is designed for use in addition to the EMR, and has easy data extraction possibilities. In an SRP data can be entered in a structured way, these systems are often disease specific. SRPs use predefined fields for data entry; data (certain selected parameters) can be entered and extracted in one way only. This results in uniformity of data with easy extraction benefits. With such a program, the caregivers have a good overview of patients with a certain disease over a specific period of time. Due to the easy extraction possibilities data can be used for research, benchmarking and care management purposes. For clinical practice, such a structured registration program means the physician has to use an extra program. Also, the structured set-up may conflict with clinical practice. Because of that, user compliance may be lower despite the advantages. However, as long as other solutions for valid and easy data retrieval are not generally available or applicable, SRP can be used.To be able to confidently use SRP data, data have to agree between the EMR and SRP programs. But evidence on this concordance is incomplete. Thiru et al reviewed the validity of data in EMRs, using data from questionnaires, consultations, survey data or paper-based information as golden standard, but most of these studies only concerned patient diagnoses as outcomes . The avaThere are several reasons why data in the SRP can differ from those in the EMR: the person entering the data can differ and only specific data gathered at a certain point in time from a particular group of patients are to be used. Differences between the recorded data in the two programs are not unlikely. As evidence on agreement between data from EMRs and SRP programs is lacking, this study was designed to assess such an agreement. Aim of the study is to examine the agreement between data from an SRP and from routine EMRs, to determine whether the use of SRP data for research and benchmarking is justified.The SRP used in this study; "Diabcare", is an integrated information technology system to monitor diabetes care, based on the St Vincent Declaration . The system consists of a form with parameter fields, which is to be completed once a year for each diabetes patient. All diabetes relevant parameters can be entered in the form: clinical parameters, results of feet and eye examinations, complications, medication, and relevant health education received  . The SRPp = 0.41) and number of diabetes patients per general practitioner .We had access to SRP data from 24 practices participating in a diabetes structured-care project (DSC) in the North of the Netherlands. The use of the SRP was part of the diabetes structured-care project. We selected ten practices to participate in this study; for practical reasons selection was based on the use of one of the following EMR systems, Promedico and Microhis. Eight practices were willing to participate. There were no differences between these eight and the sixteen other practices in mean number of patients . For identifying the same patient in the two programs we used a linking key comprised of two initials, gender, and birth date (month/year). To determine whether data from the same registration date were used in both programs, the registration date, HbA1c, total cholesterol and systolic blood pressure were compared.Records from 119 patients, mean age of 65.5 (sd = 11.9) years and 52.5% female, were collected for comparison . In most cases patient data were available for two consecutive years. However, since some practices entered the project later, for these patients only one data set was available. The SRP data obtained consisted of two records for 65% of the patients and of one record for 35% of the patients. This resulted in 196 records that could be compared between databases.Data from the EMR were collected within the general practice by two medical graduate students using a structured electronic data entry form (SPSS). Data from the SRP and from the EMR were combined into one SPSS file.The following laboratory and non-laboratory parameters were collected: HbA1c (glycosylated haemoglobin), fasting glucose, cholesterol total, cholesterol HDL, triglyceride, creatinin, microalbuminuria, blood pressure, weight, height, smoking behaviour, and foot-and-eye examination performed.A passive informed consent procedure was used for this anonymous data collection, meaning that after being informed patients could object to data collection.Collected parameters from the EMR and SRP were combined and analyzed in SPSS 12.0. In order to compare registration from SRP and EMR, we first assessed differences in the occurrence of registrations (absent or present) using McNemar tests with Bonferroni correction where p < 0.01 was considered a significant difference. Agreement regarding the occurrence of registrations was calculated using Cohen's Kappa (agreement adjusted for chance agreement).The registrations that were present in both the EMR and SRP were classified as registrations that agreed perfectly and registrations that differed. Whether differences found were also clinically relevant differences was calculated with Cohen's Kappa by determining agreement in relation to target values . Cohen's Kappa's between 0.4 and 0.75 were considered moderate to be good agreement, above 0.75 excellent. Cohen's Kappa corrects for chance agreement, but is affected by the distribution of prevalence in the marginal totals ,22. TherFurthermore, for the obtained registrations we compared the entry date between the SRP and EMR. As an overview of differences between the eight practices, a range was given for all variables. To assess the differences between the eight practices, they were rank-ordered regarding all assessments of agreement . Next, Spearman correlation coefficients were computed for rank-orders on the various assessments.No differences were found in the occurrence of registrations between the SRP and EMR for all the laboratory parameters, but regarding fasting glucose kappa for occurrence of registration was poor   values were entered more than twelve months after the EMR date (range 380-889 days); this corresponded with ten patients (8.4%). Of the non-laboratory parameters, 21 values were entered after twelve months (range 378-642 days) after the EMR date; twenty patients (16.8%).This study in routine general practice showed a good agreement between the SRP and EMR data for the laboratory parameters. No differences were found in the occurrence of registration, and data registered in the EMR and in the SRP had a similar clinical meaning for all laboratory parameters. The agreement between the SRP and EMR data was acceptable for the non-laboratory parameters. Differences were found in the occurrence of registrations of smoking behaviour, weight, eye-examination and blood pressure. Data registered in the EMR and in the SRP also had similar clinical meaning for all the non-laboratory parameters.The clinical significance was comparable for data collected from the EMR or the SRP. This implies that no parameter variation between registrations differed to such a degree that it would have any impact on decisions in clinical treatment. In the laboratory parameters, only fasting glucose had a percentage of values that differed above the 10%. However, the differences in values of fasting glucose were not of a clinical relevance.In the non-laboratory parameters some differences in the occurrence of the registrations were found. The differences that we found can be explained by differences in ease of entry of data between the two programs. In SRP smoking behaviour can be marked "yes" or "no", while in the EMR there is no such predefined entry possible. Blood pressure was registered more often in the EMR than in the SRP. A reason for this may be the fact that blood pressure is measured often and not only in a diabetes consult.Registration in SRP was the same or more complete than it was in the EMR for almost all parameters in our sample. Therefore, the extra workload of data entry in a second program did not result in less frequent registration. However, for practical implications, not only agreement between registration programs is important, but also clinical benefits, workload, and satisfaction need to be taken into account before implementing a registration program. The balance between practical usability and data entry and extraction possibilities is important; for a program to be used in clinical practice, it must meet the demands of the users ,19,23.The strengths of this study are its embedding in routine practice, the range of parameters for which comparisons have been made, and the different types of comparisons that have been made. By not only taking into account similarity between values, but also agreement in occurrence of registrations (absent/present) and clinical target values, a broad overview of comparability is provided for both laboratory and non-laboratory data. A limitation of our study is that we cannot exclude the possibility of extraction errors . Even thFurthermore, our findings may be too optimistic when compared to routine practice since GPs participating in research are usually better motivated. Although in this study main motivation of the participated GPs was the diabetes structured care, the SRP was only part of this project. Our findings regarding absent registrations are comparable with other studies, but some parameters  were indeed registered more often in our practice sample ,26.SRPs for other diseases than diabetes share many characteristics: ease of use, workload, and the variables to be entered, are all very much comparable. Therefore, we feel that the results presented here can be extrapolated to the use of other disease specific programs. This assumption is further substantiated by the fact that the clinical meaning of the various laboratory parameters were the same; parameters that are also of importance to other diseases.Data obtained from an SRP in routine primary care are comparable with data in the EMR and can therefore be used for benchmarking and research purposes. Collecting data with an SRP has the considerable advantage of easy and quick access to the data compared with manual extraction from the EMR. More research and system development is needed to optimise and standardise data registration possibilities that serve both routine care and research in general practice. Data from the structured registration program can be used validly for research purposes and quality assessment in general practice.The Medical Ethics Committee was consulted and agreed on study design (procedure was not necessary).The authors declare that they have no competing interests.All three authors made a substantial and significant contribution during the preparatory phase of this manuscript. They have all approved the final manuscript, and accept full responsibility for the design and conduct of the study; they had access to the data and approved the submission of this paper.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/9/241/prepub


Prioritization of waiting lists for elective surgery represents a major issue in public systems in view of the fact that patients often suffer from consequences of long waiting times. In addition, administrative and standardized data on waiting lists are generally lacking in Italy, where no detailed national reports are available. This is true although since 2002 the National Government has defined implicit Urgency-Related Groups (URGs) associated with Maximum Time Before Treatment (MTBT), similar to the Australian classification. The aim of this paper is to propose a model to manage waiting lists and prioritize admissions to elective surgery.In 2001, the Italian Ministry of Health funded the Surgical Waiting List Info System (SWALIS) project, with the aim of experimenting solutions for managing elective surgery waiting lists. The project was split into two phases. In the first project phase, ten surgical units in the largest hospital of the Liguria Region were involved in the design of a pre-admission process model. The model was embedded in a Web based software, adopting Italian URGs with minor modifications. The SWALIS pre-admission process was based on the following steps: 1) urgency assessment into URGs; 2) correspondent assignment of a pre-set MTBT; 3) real time prioritization of every referral on the list, according to urgency and waiting time. In the second project phase a prospective descriptive study was performed, when a single general surgery unit was selected as the deployment and test bed, managing all registrations from March 2004 to March 2007 (1809 ordinary and 597 day cases). From August 2005, once the SWALIS model had been modified, waiting lists were monitored and analyzed, measuring the impact of the model by a set of performance indexes  and Appropriate Performance Index (API).The SWALIS pre-admission model was used for all registrations in the test period, fully covering the case mix of the patients referred to surgery. The software produced real time data and advanced parameters, providing patients and users useful tools to manage waiting lists and to schedule hospital admissions with ease and efficiency. The model protected patients from horizontal and vertical inequities, while positive changes in API were observed in the latest period, meaning that more patients were treated within their MTBT.The SWALIS model achieves the purpose of providing useful data to monitor waiting lists appropriately. It allows homogeneous and standardized prioritization, enhancing transparency, efficiency and equity. Due to its applicability, it might represent a pragmatic approach towards surgical waiting lists, useful in both clinical practice and strategic resource management. Waiting lists for elective surgery (WLES) are problematic for public healthcare systems, because patients often experience long waiting times with a negative impact on health and quality of life -4. WLES At present, in the Italian public health care system patients are referred to surgeons by their General Practitioner. Patients are free to choose the surgical unit anywhere in the Public System, and upon making their specialist appointment are charged a "ticket" fee depending on the Region or possible exemption. Waiting times for the visit may vary from only a few days to several months, depending on speciality and local facilities. Surgical visits take place within the public hospital, by salary paid surgeons at which time patients are put on elective waiting list, at no extra charge. At any time patients are free to undergo private consultation and treatment, choosing where and by whom they are operated on.The aim of this paper is to propose and discuss a model to monitor and manage waiting lists and prioritize admissions to elective surgery on the basis of clinical urgency and waiting time.In 2001, the Italian Ministry of Health provided 200,000 Euro to fund the Surgical Waiting List Info System (SWALIS) project ,19, withIn the first phase of the project (model development), the steering committee performed an informal preliminary survey among the local staff of each surgical unit in the S. Martino University Hospital. A retrospective audit was then run gathering information from previous available data, searching for waiting list composition and length, management process and clinical prioritization model. Some of the most common elective surgical procedures were accessed after a long wait, in some cases lasting more than one year. The composition of waiting lists was difficult to measure because of the lack of comparable data, partly due to the contemporary internal administrative re-organization within the hospital. Only from 2005 was some comparable information available. However, waiting list related reports were considered inadequate because waiting start and end points were often undetectable, both because the database had a heterogeneous structure and because much of the data was missing.According to the Australian definition, we refer to "urgency" as the pressingness of the clinical condition and the promptness of the necessary treatment, regardless of the patient being on a waiting list . The levIn line with this distinction of the two definitions, patients gain different eligibility ("priority") during their waiting period on account of the original clinical condition ("urgency").Before implementing the SWALIS informative system prototype, a modeling study was performed by our group in order to simulate the impact of a prioritization-scoring-algorithm of this kind . The steThe scientific committee adopted Italian URGs with further minor definitions, based on two implicit semi quantitative criteria: 1) the presence of fast disease progression; 2) the grade of pain, dysfunction or disability. Each URG is associated with a MTBT, as shown in Table Every patient was registered with basic information  and underwent the same three-step pre-admission process.The clinical condition of the patient was evaluated by a surgeon on duty within the surgical unit at the first outpatient visit. Patients were registered on the waiting list in case the necessity of treatment was considered either sure or potential. Registrations were date and time stamped. Urgency was assessed according to the URGs' classification.The MTBT was automatically assigned, respecting the pre-set correspondence to the selected URG as shown in Table v, the urgency coefficient (γv) was stated by the ratio between the MTBT of the least urgent URG (i.e. URG D) and the MTBT of the corresponding URG. A time-based algorithm was computed in real time, sorting the waiting list via a dynamic priority function. For each patient the priority score at time t, P(t), was obtained by the linear product of the waiting time at time t, (t-t0) where t0 is the registration time, and the respective urgency coefficient (γv), such that:URGs were associated with an urgency coefficient, representing the speed at which the clinical need is assumed to increase along with the passing of time. For each URG Following this equation, patients proceeded in the list at different speeds according to their urgency, gaining different priority scores, given the same waiting time. Note that P(t) is expressed in days weighted for urgency coefficient, which is Need-Adjusted-Waiting-Days (NAWDs), standardizing waiting times among different URGs .Patients who were subjected to hospital postponements were still prioritized following the same rule.A system prototype was developed by using open source technologies . The sofIn the second three-year project phase (model experimentation) the model was deployed and its effects were observed. The hospital's ethic committee disapproved the start of any randomized or control study owing to legal reasons while no retrospective comparison was possible because of the lack of local comparable data prior to the SWALIS model's deployment. A descriptive prospective study was then designed and performed, monitoring the experimentation and measuring the impact of the model by a trend analysis of time series under its homogeneous application.A single general surgery unit was selected within the ten surgical units as a pilot test bed for deployment and on-field application. At the beginning of phase 2, the model was subjected to a fine-tuning period, from March 2004 to July 2005, when URGs were assigned to all registrations. This was followed by a monitoring period, from August 2005 to March 2007, when the full model was applied in the clinical practice as the standard pre-admission process and waiting lists were measured together with the performance of the prioritization.Surgeons explained to their patients the URG assignment, the expected MTBT and the prioritization algorithm. Waiting list managers (day-time and head nurses) looked after the process and planned admissions using the SWALIS software. URGs distribution was collected from different categories such as type of admission, presence of neoplasm, International Classification of Diseases (ICD) general coding, and duration of surgery.The project steering committee devised control surveys, collecting information every three months to monitor the experimentation, the involvement of users, their training and feedback, system prototype faults, and waiting list performance. The general status of the experimentation was updated including information about the involvement of the surgical units and the input of new registrations. The continuous system control included the prioritization module and the standard application of the SWALIS admission rule.Most database parameters were controlled weekly together with the integrity, completeness and update of the waiting list data. Waiting list back office performance indexes were monitored on a monthly basis as soon as they became available.Surgeons' clinical referees actively collected feedback by their colleagues and by the surgical unit's waiting list managers. Difficulties which arose during data entry, viewing and updating the system, were monitored as well as those in URGs and ICD assessment. Users were also asked about the perceived usefulness of the model. All information was organized into periodical synoptic reports and discussed during the steering committee's quarterly meetings.per se. Assessment subjectivity was not investigated with proper tools (i.e. inter-rater or intra-rater reliability) in this study; however, other experiences described a relevant subjectivity in the use of similar implicit urgency criteria [The SWALIS project adopted the Italian URGs because of their National value and considered them as rules to be applied focusing on the experimentation of the entire model rather than on the clinical urgency criteria criteria . With thRound table meetings took place within the pilot unit every three months. All nine surgeons and the two waiting list managers on staff participated. The clinical referee led the meeting, while the waiting list managers took notes and presented the audit material. Each meeting was divided into two parts.The first part was semi-structured as a broad inspective internal audit lasting 45 to 50 minutes, during which time reports about registrations of the previous three months were shown. Each of the following points was presented and discussed until surgeons reached a final agreement.1. Broad analysis of URGs assessment in more common (ICD based) clinical cases.2. URGs assessment for rare diagnosis and treatments.3. Single registrations with URG deviating from the more common distribution.4. Single registrations with reported difficult assessment.5. Comparison of URG assessments among surgeons.The second part of the meeting was an unstructured 15 minute open discussion about any relevant problems.The effects of SWALIS model application were preliminarily observed during the fine-tuning period, early in project phase 2 . Once th General Public License . Sources and binaries for R software can be obtained via Comprehensive R Archive Network . At the time of writing this, R-2.7.1 was available [Results are expressed as mean +/- standard deviation (SD), median, and 95% confidence interval (CI). Graphics and statistical analyses were performed using R software/environment, an open source project that is distributed under the GNU During the entire three-year model experimentation phase, from March 2004 to March 2007, 45 surgeons and 22 nurses were involved. The SWALIS database was queried and N = 113) errors were deleted prior to final analysis. During the monitoring period, from August 2005 to March 2007, the system prototype service rate remained constant, waiting lists were fully updated and 100% of admissions in the pilot unit were planned using the SWALIS algorithm. Table  errors wThe SWALIS model was routinely utilized for several diagnoses and surgical procedures, belonging to most of the general categories (classified by ICD coding), and in the presence (or absence) of benign or malignant neoplasms.No relevant conflict emerged from either users or patients. The system provided functionalities to schedule admissions and appointments, establishing how patients' priority would change in relation to the expected waiting time.During control surveys, waiting list managers reported the SWALIS system to be a useful tool to reduce postponements due to more efficient planning. They also described the perception of an increase of safety, due to the possibility to check for exceeding waits at a glance rather than going through the paper registry.Surgeons reported some initial apprehension about structuring their clinical judgment and entering a more auditable area. They also expressed some concern about the competition of their respective patients due to the risk of subjectivity in URGs assessment as described in Victoria . NonetheThe system prototype provided the rich set of waiting list data and detailed performance parameters described in table Table We demonstrated no trend in length of the list or in the overall mean waiting time, as neither parameter had the tendency to change, though variable in time Figure . AnalogoData in table As Figure WLES management is a critical issue, since the demand for surgery often overwhelms supply and public systems have limited resources. The application of effective policies is still a rising concern, given no definite standard is available to measure and handle the problem. The matter is then far from being comprehended and its intrinsic complexity has been recognized for more than two decades . Likely Given the obscurity of the matter, the SWALIS model was designed with the intention of obtaining transparent data to gain a more in depth understanding of WLES, enhancing prioritization as a leveraging instrument through the use of information technologies. Feasibility and accessibility emerged early on as qualities necessary for the new model, since its application was expected to cause substantial organizational change. The model was then designed incorporating clinical urgency assessment and real time prioritization sequentially. Such a multi-module structure was chosen in order to include the whole pre-admission period, so as to adopt different clinical urgency criteria and to manage any elective surgical procedure. The system was built to provide data and prioritization in a single software environment, becoming a useful tool in the real practice. As a result, the entire demand for surgery was processed consistently, including a very heterogeneous set of clinical conditions and surgical procedures. The integration of adequate indexes within the model allowed the measure of WLES performance, obtaining the necessary information to better understand their composition and trends.The display of patients' respective priority Figure  allowed Admissions and surgical resources could be planned quickly by the use of an intelligible forecast, visualizing how many patients – and which of them – were to be admitted in the near future . It was easier to keep them in really elective conditions reducing the amount of time they waited. This in turn reduced the need for unexpected bed and operative room occupation for sudden clinical deterioration, often resulting in complicated surgery and prolonged postoperative periods as a consequence of excessive waiting times . FurtherThe availability of waiting time data, either as waiting time distribution Figures  and 3 orThe availability of data regarding waiting list composition and dimensions Figures , 3 and 4Additionally, the standard application of the model to all registrations allowed the SWALIS system to serve as the proper environment to manage the clinical added information . The software allowed relevant synoptic information to be retrieved  and to be delivered to respective users, such as surgeons or waiting list and health managers.Urgency assessment is a crucial topic since it represents the main milestone of the entire prioritization process. Given the absence of great international agreement on the subject, it may represent a weak point of our study, since we have not investigated it with proper tools. With this limitation, we started from the application of the Italian implicit urgency criteria because of their statement at a national level. While the rater reliability of the Italian criteria might be further assessed and/or more objectively defined, in our experience they proved to be easily applicable to the entire pool of patients, allowing both coherent data collection and patient prioritization. In order to maintain this adaptability, our model has implied the formal separation of the three steps , allowing the possible introduction of different clinical criteria if necessary.ad hoc measures were taken to prevent it from happening [Urgency assessment was taken into great consideration, since surgeons' clinical judgment was required to be both free and objective. As described in other experiences, a certain amount of guesswork to elevate patients' URG most likely occurred, even though the phenomenon was discouraged and appening . In our Patients were not asked directly about their experience under SWALIS experimentation, neither in interviews nor by questionnaires, and the impact of the model on patients might be further investigated. With this limitation, during control surveys surgeons and nurses were asked to report issues that emerged at the time of outpatient registration on the list, during the waiting period and at the time of admission.They described no relevant problem in explaining the criteria of their urgency assessment and reported that patients generally acknowledged that waiting time should not hold the same value for them all but be based on the grade of their illness. On those occasions, patients accepted that waiting time could weigh proportionally to their respective URG and no complaints for being overtaken by more urgent patients were ever reported. We interpreted this finding as mostly due to the national statement of the URGs classification, since an understanding of the prioritization's consistency led to an increase in its level of acceptance . The posRegarding the patients' acceptability of waiting periods, it is known that they often suffer from consequences of extensive waiting periods, and that many of them may have different opinions of waiting times ,4,34. ThAssuming that free access does not automatically imply immediate healthcare delivery, our model was designed to treat patients at the right moment, satisfying their respective need. The SWALIS model adopted the waiting time as the unique non-clinical criterion, not only admitting patients by classifying them into URGs (and within their MTBT), but also by scheduling admissions using a progressive scoring system .Rather than in waiting list length, the effects of the SWALIS prioritization process are evident within the waiting list composition in real time, since the prioritization algorithm determines a change of their internal sorting continuously, so that every registration will reach the top of the list by its priority score Figure . This clAs expected, the application of the SWALIS model caused no evident effects in terms of reduction or increase of the overall waiting list length (demand side policy), because resources (beds and operating room availability) was set as constant. Reducing list consistency would require increasing service rate (supply side policy) and the variability shown in Figure In this study we observed no significant difference in the time series. Even so, by the physiological functioning of the SWALIS model, waiting list observation should result in API moving close to the 100% for all different URGs. We consider this point to need further investigation but this general progressive tendency appears in the latest monthly data in Figure As some of the authors published separately, the application of the SWALIS model brings an increase in efficiency as well as equity . AccordiHorizontal inequities were avoided because the algorithm calculates priority proportionally to waiting time. With the exception of the few patients in category D , this assumption is supported by the comparison of the overall mean and median waiting times of the respective URG, where overall cross sectional waiting times are inferior to the correspondent retrospective ones. This data give evidence to the fact that patients were admitted only after those in the same urgency category that had been waiting longer.Vertical inequities were avoided by computing the priority on the basis of clinical urgency. The overall waiting times of each URG showed increasing values with the increase of their MTBT, meaning that the more urgent patients were not waiting as long as those in less urgent categories and were admitted earlier.Table As it has happened in Victoria since 2005 , proper The SWALIS model might represent a suitable test bed for different urgency criteria, more objective definitions (i.e. oriented to specific procedures), higher standards , and rater reliability of the clinical assessment. The model might be tested in wider and more heterogeneous environments and its user pool might be expanded, including the management level. Given the model is applied by a complex technological interface, the perceived usefulness and applicability of the prioritization should be assessed together with the user ware of its software environment . The assSince 2003 the SWALIS model has undergone testing in two hospitals in Northern Italy, by different software prototypes . In 2007, the Administration of Liguria Region stated the progressive diffusion of the model in its territory and, as of 2009, another general public Hospital in Genoa  will be adopting the model.The methods to measure and control WLES are far from being standardized worldwide. The model we propose involves a relevant organizational change in the surgical pre-admission process but it is applicable and appropriate to include different clinical urgency criteria. The SWALIS model would benefit from further validation but according to our experience it allows the use of a homogeneous and standardized method of prioritization. It is suitable for being applied to all patients who are candidates for elective surgery and it allows effective monitoring of waiting lists. As a result, it allows scheduling hospital pre-admission paths efficiently, gathering, retrieving, and sharing considerable information, integrating the different roles in a common environment, and making individuals able to manage problems that need a collaborative solution. It allows orienting resources towards patients in most need, taking a step towards transparency and efficiency, and protecting patients from horizontal and vertical inequities. Due to the accessibility and the applicability of its prioritization algorithm, our model might represent a pragmatic approach to the management of WLES. Its embedding into software environments might be useful in clinical practice and strategic management.API: Appropriate Performance Index; ICD: International Classification of Diseases; MTBT: Maximum Time Before Treatment; OMWT: Overall Mean Waiting Time; NAWDs: Need Adjusted Waiting Days; URGs: Urgency Related Groups; SWALIS: Surgical Waiting List Info System; WLES: Waiting List for Elective Surgery; WP: Waiting Patients.The authors declare that they have no competing interests.RV conceived and coordinated the study, participated in its design, analysis and interpretation of the data, and drafted and supervised the manuscript. AT participated in the study's conception and design, supervised the analysis and interpretation of the data, and co-drafted and revised the manuscript. ET contributed to the study's conception and design, performed analysis and interpretation of the data, and participated in drafting and revising the manuscript. MF participated in the study's conception and design, supervised system development and revised the manuscript. IP contributed to the study's conception and design, performed system development, performed the data management of the study, and participated in drafting and revising the manuscript. MS participated in the study's conception, design and management, in data acquisition and system testing, and participated in revising the manuscript. GS was involved in data analysis, in drafting and revising the manuscript, and revising it critically for important intellectual content. GT participated in the study supervising the system development and testing in the surgical department and gave important intellectual content. GA participated in the study's conception, design and management, in data acquisition and system testing in the surgical department, and participated in revising the manuscript.All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Environmental Health Perspectives (EHP) should note that we have revised our Instructions to Authors. The revised Instructions to Authors are included at back of this issue and are available on the journal’s website (http://www.ehponline.org/). Four points bear special attention.Authors planning to submit manuscripts to First, over the last several months, it is has become clear that the journal needed to provide more guidance concerning reviews. Please note that the journal now has three categories of review papers:Substantive Reviews provide an overview, integration of information, and critical analysis of a particular field, research, or theme related to environmental health sciences. The strengths and weaknesses of individual studies and weight of evidence should be discussed. In addition, we encourage authors to identify research gaps and make recommendations for future research.Quantitative Reviews and Meta-Analyses present and contrast—and when appropriate, combine—data across studies to address a specific question related to environmental health sciences. Authors should provide inclusion criteria and strategies used to search the literature, and discuss strengths and weaknesses of studies as well as potential causes of discordant findings. As in the case of Substantive Reviews, we encourage identification of research gaps and recommendations.Emerging Issue Reviews identify emerging ideas, concepts, or trends in the area of environmental health sciences. They should have a highly focused narrative and a limited set of references. Emerging Issue Reviews, limited to 5,000 words, undergo an expedited review process.Second, authors should be aware that the journal is placing greater emphasis on word limits for submissions. Papers exceeding the word limits described in the Instructions to Authors will be returned to the authors before being considered for peer review. We suggest placing some types of materials, such as lengthy descriptions of previously published methods, into Supplemental Material. However, a brief description of methods in the main body of the manuscript is required. Because references contribute considerably to the length of most papers, authors should include only the most relevant citations.American Medical Association Manual of Style: A Guide for Authors and Editors, 10th edition .Third, each manuscript is now routinely checked for possible plagiarism before peer review. Definitions of four common kinds of plagiarism are described in the Finally, a number of readers have recommended that abstracts should contain a clear statement about the potential impact of the research findings on the area of environmental health. Authors are encouraged to include a statement about the impact of their research in the Conclusion or Relevance section of their abstract.


Measuring only 188 × 127 mm, it is in the size of any typical medical handbooks available .Various cancers are discussed in details including their demographic information, pathogenesis, clinical features, management and prognosis. The information provided is concise and yet sufficient for a good understanding of the general principles of oncology and specific cancers. Besides that, the author also discusses various future perspectives and the on-going development in oncology which certainly encourage the reader to explore for new ideas in the challenging world of cancers.This reader friendly book will be useful and handy to medical students, scientists, clinicians and health-care professionals who have interest in oncology. The medical students will be able to gain a clear understanding of the general principles of oncology and various types of cancers. Meanwhile the clinicians, health-care professionals and scientists may use this book as a quick reference and a reminder of the features of the various cancers.Finally, we would also recommend each oncology ward to have a copy of this book in the desk especially for its concise and yet invaluable contents. Furthermore, it will hardly take up much space just like any British National Formulary or Oxford Handbooks.The author(s) declare that they have no competing interests.


The "Law of the Designation and Operation of the Free Economic Zone", which goes into effect September 28, 2007, will allow foreigners to establish medical institutes in the Free Economic Zone, which includes the Korean cities of Busan-Jinhae, Incheon, and Kwangyang. Physicians and dentists with a license from a foreign country will be allowed to practice in those institutes, and treat Korean patients. The government anticipates that this policy will reduce the expenses of medical travel, improve service for Koreans, and strengthen the competitiveness of Korean medical institutes in the global market. The policy's primary objective is to aid foreigners in Korea, but it is also designed to increase foreign investment in Korea. The purpose of these policies is very clear. However, regarding the basic health rights of people in Korea, both Koreans and foreigners, the accreditation of foreign licenses, without the stipulation that such licenses conform to Korean law, does not meet global standards. If the Korean Government wants to allow foreign medical health personnel to practice in Korea, a mutual agreement on the accreditation of licenses between corresponding countries is necessary. A medical VISA is not an unconditional accreditation, and test-equating procedures are required at the levels of undergraduate training and graduate training, as well as that of continuing medical education.Also on July 6, 2006, the Minister of Health and Welfare of the Republic of Korea announced the revision of its "Enforcement Regulation for Medical Law," which was rejected by the Minister of Government Legislation since it violated the "Medical Law." The proposed revised content follows:Foreigners with a medical health license, such as physicians, dentists, or nurses, can treat people from their homeland who are residing in Korea, when employed by a general hospital or clinic as defined under "Medical Law," to guarantee the health rights of foreigners residing in Korea.Because the Korean Government is greatly concerned about the health of foreigners working in Korea, this kind of revision was launched. However, because the revision targets temporary immigrant laborers, the medical expenses will be not be great. The general hospitals or clinics should decide on whether to hire foreign medical health personnel after considering the number of patients it commonly treats. Although the government will allows medical institutes to hire foreigners, active recruitment depends on the market. It is questionable whether other Organization for Economic Co-operation and Development (OECD) countries offer this kind of system to foreigners residing in their countries. Although the revision was rejected by the Minister of Government Legislation, it was said that officer of Health and Welfare will try again the revision of "Medical Law" instead of "Enforcement Regulation for Medical Law." If it is tried, there is a high possibility that this revision is passed.Furthermore, Korea and the United States announced the Korea-United States Free Trade Agreement (FTA) on April 2, 2007. A "specialist service working group" will be created to discuss the mutual accreditation of specialists. The first round will include the fields of engineering, architecture, and veterinary medicine. It is uncertain whether medical health personnel will be included in the next round. Korean Medical Association (KMA), the official organization of physicians in Korea, asked the Korean delegates of the FTA for a mutual medical VISA quota to the United States, but this request was not considered at first. Corresponding officers of governments have noted that they would try to negotiate with Congress of the United States since it is the area of immigration. Korea also began discussing the FTA with Canada on July 2005, and talks with the European Union will begin on May 7, 2007.However, before proposing mutual accreditation for medical health licenses, it may first be necessary to develop a scientific foundation for test equating and educational standardization. The mutual agreement of medical health licenses may become an ongoing issue. Before any such agreement can be made, or a one-sided inclusion of foreigners is accepted, test equating should be considered and the data should serve as a scientific base. In the very near future, Korea will be open to foreign medical health personnel. Some foreigners will have the opportunity to practice in Korea. It is time to consider the health rights of the people living in Korea, and to question why each country has its own accreditation system. It may be difficult to equate licensing examinations between corresponding countries because these are high-stake tests. Due to different cultural backgrounds, and different epidemiological data, it is also difficult to test similar items in such exams. In this case, common items can be prepared in each language, but such an approach will not meet the strict definition of test equating until after they have been tested for validity and reliability. For this kind of test equating, at each level of education, internet- and computer-based testing (iB-CBT) are the best tools. Computerized adaptive testing (CAT) can also be used. This kind of test equating can also be applied to clinical skill tests or to objective structured clinical examinations (OSCE) via iB-CBT. To assess such test equating, it should be applied to at least two medical schools in two different countries or, ideally, to several medical schools in several countries. Then test equating between hospitals and between continuing medical education institutes could be launched. Test equating may be one of methods of the evaluation of medical health personnel of different countries. To this end, psychometrician's consultation is not only necessary, but physicians must understand psychometrics.


Studies carried out in the community enable researchers to understand access to medicines, affordability, and barriers to use from the consumer's point of view, and may stimulate the development of adequate medicines policies. The aim of the present article was to describe methodological and analytical aspects of quantitative studies on medicine utilization carried out at the household level.Systematic review of original papers with data collected in studies in which the household was a sampling unit, published between 1995 and 2008. The electronic review was carried out in Medline/Pubmed, Scielo and Lilacs. The reference lists of the papers identified were examined, as well as other publications by their authors. Studies on the utilization of specific pharmacological groups, or those including only respondents with a given disease were excluded.Out of 4852 papers initially identified in the literature search, 61 fulfilled our inclusion criteria. Most studies were carried out in Europe and North America and used a cross-sectional approach. More than 80% used face-to-face interviews for data collection, and the most frequently used recall period for assessing medicine utilization was 14–15 days. In 59% of the studies, interviewers were trained to request the packaging of the medicines reported by the subjects; medical prescriptions were requested less frequently (15% of the studies).These data will be useful for updating researchers on what methods their peers are currently using. Such information may help overcome challenges in the planning and analyses of future studies. Moreover, this publication may contribute to the improvement of the quality of medicine use data obtained in household surveys. Studies on the overall prevalence of medicine utilization are frequent in the scientific literature. Such studies are characterized by the investigation of any medicine used within a defined period of time. These studies represent an important tool to be used in health system evaluation. InformatIn low and middle-income countries, in general, there are no computerized systems that integrate the information about medicines. Therefore, in most cases, it is not possible to carry out medicine utilization studies based on this source of information. As a result, researchers usually rely on studies with direct interviews with consumers, or investigate medical records, which are often incomplete. Taking into account that studies based on questionnaires are subject to reporting bias, it is important to use a carefully designed methodology for data collection.The primary aim of this review is to describe the methodologies used for collecting and analyzing quantitative data on medicines use in household surveys. The paper also analyzes qualitatively the methodologies employed in the reviewed studies, and provides recommendations for future studies in the field.A literature review was carried out using the Pubmed, Scielo and Lilacs databases. The following keywords were searched in the title or abstract of the papers: "drug(s) use", "drug(s) utilization", "drug(s) utilisation", "drug(s) usage", "drug(s) consumption", "medication use", "medication utilization", "medication usage", "medication consumption", "medicine(s) use", "medicine usage", "medicine consumption", "self-medication", "over-the-counter".Several restriction criteria were used in the electronic search: (a) only articles published in Portuguese, English and Spanish were considered (only four papers were excluded due to this criterion); (b) only studies published between January 1995 and June 2008 were included, in order to focus on a description of the survey methods in current use; (c) only original papers were included. Studies in hospitals, schools, universities, nurseries, pharmacy counters, health clinics, and workplaces were excluded, as well as those including only institutionalized individuals (nursing homes and prisons). Finally, studies investigating the specific use of a given pharmacological group or including only individuals with a given morbidity were not considered.Using the keywords mentioned earlier in Pubmed, 4852 titles were found until July 2005. After reviewing their titles and abstracts, 134 original papers appeared to fulfill the inclusion criteria, and therefore, their full texts were obtained. From July 2005 to June 2008, the same search strategy was automatically repeated in Pubmed. The searches at Scielo and Lilacs added few publications, and were made in July 2005, April 2006 and June 2008. Articles detected in the electronic search were reviewed by two of the authors, who decided whether or not the manuscript fulfilled the inclusion criteria. When they disagreed, the article was discussed by the two until a final decision was reached, based on the inclusion and exclusion criteria.The references of the selected papers were reviewed in order to find other eligible publications. A search by the names of all first authors from the selected papers was also made. In seven cases, in which more than one publication was based on the same data, only the first was included in our review. After a detailed examination of the selected papers (obtained in full), 61 fulfilled all inclusion criteria.The original papers included in the review were classified according to several characteristics:- Country of data collection;mixed';- Continent of data collection: studies carried out in more than one continent were denominated '- Design used: cross-sectional, cross-sectional nested within a longitudinal study, and longitudinal;- Age groups: all ages, children only, adolescents and adults, elderly only;- Sample size: divided into ≤ 1000, 1001–5000, >5000 subjects;- Sampling strategy: utilization of a random sampling strategy or not;- Questionnaire administration mode: face-to-face interview, postal questionnaire, self-administration and telephone;- Respondent: medicine user, medicine user and proxy, medicine user and parents, parents only, family breadwinner or any resident;- Presentation of the survey questions that define the use of medicines in the article: yes or no;- Presentation of data on the validity of the questionnaire used for evaluating medicine utilization: yes or no;- Type of questions used to investigate medicine use: (a) open ended questions ; (b) checklists .- Request for packaging presentation: yes or no;- Request for prescription presentation: yes or no;- Types of medicines investigated: medicines for chronic use, medicines for acute use or both;- Indication of medicine taking: investigation of prescribed, over-the-counter or both types of medicines;- Pharmacological group classification: classification system used for dividing medicines into pharmacological groups;- Denominator used in the analyses: individuals, medicines or both;- Recall period: as described in each article.Additional file The most frequently used recall period was 14 days, or two weeks, although the periods ranged from one day to two years , incomplete information  or even wrong information (due to misunderstanding either the question itself or the medicine treatment in use) ,64. As aThe following sections discuss several key methodological aspects of household surveys on medicine utilization, summarizing the strategies used in the reviewed studies, quantified in the results section, and presenting directions and recommendations for future studies in the field.One of the most important methodological aspects in investigating medicine utilization through questionnaires is the definition of the recall period to be used. There is no consistency in the literature regarding the ideal recall period to investigate medicine utilization. However, it is known that the prevalence of medicine utilization is extremely dependent on the recall period. For example, two population-based studies carried out two years apart in Pelotas, Brazil, using similar methodologies, found prevalence of antimicrobial use in adults of 7.3% using a recall period of 30 days, and of 5.4% using a recall period of 15 days. Another The main methodological issue related to the choice of the recall period is the difficulty in accurately remembering and reporting use within the period. Van den Brandt et al showed tThe main question to be answered when selecting recall period is: to what extent it is reasonable for the sample of respondents in this study to accurately recall details of medicines taken for the period in question? Difficulty in remembering is likely to be greater for longer period, but the Self-prescribed medicines are especially sensitive to difficulty at remembering. A study There is no ideal recall period for investigating medicine utilization, because selection of recall period depends on what is to be recalled and ability of the respondent population to remember. If the goal is to compare the data with most studies in the literature, two weeks (14–15 days) is the recommended period. There is a tendency in the literature that studies on acute illnesses use shorter recall periods in comparison to those on chronic illnesses.The procedure for administering the questionnaires  is another important methodological aspect to be considered. A recent Brazilian study about meIn low and middle-income countries, telephone coverage may be quite low, and studies using this approach are likely to be affected by selection bias. High illiteracy rates, also frequent in less developed countries, make self-administration challenging. Finally, because response rates are quite low for postal questionnaires, studies using the face-to-face approach are recommended, particularly in low and middle-income countries.Other relevant questions for household surveys on medicine utilization are the suitability of the terminology used, the cleaIn the study by Flores, it was In summary, researchers should use simple, but technically correct terminology. Efforts should be made to state clearly the definition of medicines to be used in the study, and special attention should be paid to prompting respondents for information about analgesics, natural products, medicines for topical use, and others that they may consider to be 'less important'.Kimmel et al studied Open ended questions are preferred for studies evaluating overall medicine utilization. Checklists should be used when authors are particularly interested in a given disease, pharmacological group or specific medicine names. The question(s) used for assessing medicine utilization should be presented in the articles, so that other researchers can replicate the method in future studies. Unfortunately, the majority of studies reviewed did not present the main question used to assess medicine utilization.Because most studies on medicine utilization include elderly subjects, methodological attempts to improve the accuracy of the information on medicine use are a priority. Medicine use of the elderly differs considerably from other age groups. The highIn order to minimize this problem, some researchers have opted to interview close relatives or caregivers for the total or partial collection of information about medicine utilization. In some Excluding elderly subjects without ability to answer a questionnaire on medicine utilization will underestimate the prevalence of medicine use, because these subjects are more likely to have medicine utilization. Therefore, the utilization of proxy information is recommended, particularly in studies with elderly subjects. Finally, authors should mention in the articles whether or not this strategy was used, so that other researchers would be able to replicate the methodology used, and correctly interpret the findings of the study.One way to validate the data on medicine utilization and even to add recall about what was used in a specific period is to ask for the medicine packaging. This strategy is particularly useful in household studies, where, medicines tend to be stocked. As presented in Additional file The request to see prescriptions may also be used to validate or qualify the data collected, because researchers may be able to correctly identify the name and characteristics of the medicines taken. In spite of its potential benefits, this strategy was used in only 15% of the studies reviewed.Most household surveys on medicine utilization investigated medicines for treating both chronic and acute diseases. However, characterization of what constitutes regular use differs across studies. Some approaches are: use of medicine habitually; use of mConsidering that the terminology used may affect the interviewee's answer, it is important to clarify exactly what is intended. For example, oral contraceptives are medicines used regularly, but they are not used to treat chronic diseases as the majority of the other medicines included in this group.Another issue to consider is the duration of time using a medicine in order to it to be considered chronically or habitually used. Some prophylactic treatments with antibiotics are long, but temporary. Should they be considered for chronic or acute use? In this sense, the utilization of terms like "habitual" or "chronic" seem to be more appropriate than the definition based on the number of days in treatment. The term "without date to stop" may be a useful alternative to differentiate the types of medicines.When the study requires a classification into pharmacological groups, the quality of the information is a concern, and presentation of the medicine packaging or prescription is a useful practice. Almost hMany medicines have two or more indications; in order to classify medicines into pharmacological groups, it is essential to know which health problem the medicine was used for. In the case of acetylsalicylic acid, for example, the ATC code N02BA01 would identify use as an analgesic, while B01AC06 would identify use as a platelet aggregation inhibitor.There is no ideal system for classifying medicines into pharmacological groups. However, it is extremely important that authors mention the system chosen, in order to allow comparisons across studies.Medicine utilization may be analyzed using either the total number of subjects in the sample or the total number of reported medicines as the denominator, which can lead to very different conclusions about the prevalence of use of different types of medicines. Some studies do not inform about which kind of denominator was used in the analyses, making it difficult to interpret the data or compare across studies.In studies of individual determinants of medicine utilization, the denominator should be the number of subjects in the sample. In studies on the characteristics of the medicines used, both approaches have been used. In the first approach, each line in the database will correspond to a subject, while in the second one, each line in the database corresponds to a medicine used. This aspect was recently discussed in a review paper.In studies of specific pharmacological groups, one may be interested in reporting the prevalence of antimicrobial use in the studied population  or the proportion of antimicrobials in the total number of medicines used in the sample (denominator = number of medicines).In a study about utilization of generic medicines, both appThe present review focused on the methods used in 61 household surveys of medicine utilization published between January 1995 and June 2008. These data will be useful for updating researchers on current standards of practice, and may help overcome challenges in the planning and analyses of such studies. Moreover, recommendations in this publication may help to improve the quality of the data about medicine use obtained in household surveys.Given that studies are conducted for different purposes, a certain degree of heterogeneity in methods is expected. However, standardization of certain practices would be beneficial. For example, international and regional comparisons of medicine utilization prevalence would benefit from the utilization of consistent methodologies. Actually, the World Health Organization has tried to overcome the problem, by proposing standard instruments. In the 2002 World Health Survey, a standardized questionnaire including some questions on medicine access, affordability and use, was administered in 53 countries.Regardless of the issue of standardization, some publications lack important details on the methodologies used, for example, the system used to classify medicines into pharmacological groups or the question used to investigate the main outcome variable. Authors should provide such details in the articles, so that other researchers may adequately replicate studies in different settings. Finally, because data on the reliability and validity of medicine use questionnaires are rare, it is uncertain if the instruments currently in use are accurately assessing the construct of medicine utilization.The authors declare that they have no competing interests.ADB led the literature review process, the writing and analyses of the manuscript. AJDB, AW and DR-D approved the search strategy, revised the text and contributed in the planning of the review. PCH conducted the literature review with ADB, assessed each article in terms of the inclusion criteria and helped writing the manuscript and analyzing the data.The pre-publication history for this paper can be accessed here:Table 1. Quantification of methodological characteristics of the 61 household surveys on medicine utilization included in the review.Click here for fileTable 2. Description of the studies included in the review according to methodological characteristics – part I.Click here for fileTable 3. Description of the studies included in the review according to methodological characteristics – part II.Click here for file