It has been postulated that patients admitted on weekends or after office hours may experience delays in clinical management and consequently have longer length of stay (LOS). We investigated if day and time of admission is associated with LOS in Tan Tock Seng Hospital (TTSH), a 1,400 bed acute care tertiary hospital serving the central and northern regions of Singapore.st September 2003 to 31st August 2004. Data was extracted from routinely available computerized hospital information systems for analysis by episode of care. LOS for each episode of care was log-transformed before analysis, and a multivariate linear regression model was used to study if sex, age group, type of admission, admission source, day of week admitted, admission on a public holiday or eve of public holiday, admission on a weekend and admission time were associated with an increased LOS.This was a historical cohort study based on all admissions from TTSH from 1In the multivariate analysis, sex, age group, type of admission, source of admission, admission on the eve of public holiday and weekends and time of day admitted were independently and significantly associated with LOS. Patients admitted on Friday, Saturday or Sunday stayed on average 0.3 days longer than those admitted on weekdays, after adjusting for potential confounders; those admitted on the eve of public holidays, and those admitted in the afternoons and after office hours also had a longer LOS .Cases admitted over a weekend, eve of holiday, in the afternoons, and after office hours, do have an increased LOS. Further research is needed to identify processes contributing to the above phenomenon. Optimising of length of stay is one approach to improving hospital performance, particular under funding systems that quantify outputs by the episode of care, as unnecessary inpatient bed-days constitute a significant component of per-episode costs. Casemix funding of inpatient services was introduced to Singapore in October 1999,[Contribution to inappropriate LOS may include patient, disease-related, as well as institutional and organizational factors. While the actual factors differ for various individual DRGs, it is foreseeable that certain institutional factors may cut across multiple disciplines and disease groups in a systemic fashion. From a hospital administrator's perspective, it would be useful to look at the overall group of patients and identify such institutional and organizational factors as well, as these could be amenable to the reorganization of service delivery at the institutional level.Clinicians and other front-line staff have often suspected that the reduction of service capacity over the weekend delays the investigation of new cases, hence prolonging the length of stay. This effect would be most pronounced in cases admitted just before, or on the weekend itself, since the initial workup for the admission episode would be delayed for these patients. There is some published evidence that day of admission and access to health care services can affect LOS. A study in Germany on stroke patients showed that LOS is associated with the day of the week the patient was admitted Another We hence set out to examine if day and time of admission is associated with length of stay among TTSH inpatients, while adjusting for possible differences in the timing-related profile of admission episodes.st September 2003 to 31st August 2004 were included in the analysis. Those who died were excluded from the analysis . In addition, we excluded day surgery cases and other inpatient stays with less than one day.This was a historical cohort study design on patients admitted to TTSH, a 1,400 bed acute care tertiary hospital serving the central and northern regions of Singapore. Admissions from TTSH from 1We used only data from routine administrative sources that are part of the Hospital Management Information Systems. Data on admissions and discharges was extracted with the assistance of the information technology department, and organized by the episode of care. Further data management was performed in MS Access 2000 to process the additional covariates of interest with regards to day of week, relation in time to public holidays, and the timing of the admission episodes.We then used the multivariate linear regression model to study the factors affecting length of stay, with eacAmong the covariates studied were sex, age group, type of admission, admission source, day of week admitted, admission on a public holiday or eve of public holiday, admission on a weekend  and admission time . For the final model, we checked for normality and heterogeneity of the residuals and used the variance inflation factor (VIF) to examine multi-collinearity between explanatory variables[There were 45395 episodes of care included in the analysis for the study period. Table In the univariate analysis, we found that sex, age group, type of admission, source of admission, class on admission, day of week admitted, admission on a public holiday, eve of public holiday and weekends and also time of day admitted were significantly associated with length of stay Table .However, in the multivariate analysis, only sex, age group, type of admission, source of admission, admission on the eve of public holiday, admission on weekends, and time of day admitted were independently associated with LOS Table .In terms of demographics, males generally stayed around 0.3 days lesser than females, and those who were older stayed longer. Those who were admitted on weekends stayed on average 0.3 days longer than those admitted on weekdays, after adjusting for the other significant covariates shown in Table Elective admissions stayed around 2 days lesser than emergency admissions, and this was also found to be statistically significant (p < 0.001). For source of admission, direct ward-to-ward admissions stayed the longest. However, this association was likely confounded through an artifact of administrative classification, as most of these were cases admitted from another service within the hospital to the neurology service (NLD and NSD), which functioned under an independent management within TTSH; the observed increased LOS in ward-to-ward admissions hence reflects the complicated nature of this special group of admission episodes. There was a change in direction of effect for those admitted from SOC after adjusting for other covariates. In the univariate analysis, we found that SOC admissions stayed lesser than emergency admissions, whereas in the multivariate model, SOC admissions stayed longer. This could be due to the suppressor effect of other confounders, in particular the type of admission, which is partially correlated with the source of admission.In addition to the overall model, we did further sub-group analysis, by studying the difference in LOS by the top 5 admitting disciplines by volume. As we can see in Table We also performed a stratified analysis for 28,739 admissions for which DRG codes were available at the time of data extraction (mostly in admissions from the earlier two thirds of the dataset), focussing on the difference in LOS for weekend and weekday admissions. The results for the top three DRGs by volume for the above 5 disciplines are presented in Table To determine if the effects on LOS could be explained by differences in disease severity, we also stratified the analysis into direct admissions to intensive care / high-dependency units (ICU/HD), and admissions to the general ward (GW). The adjusted difference in average length of stay among 1517 direct admissions to ICU/HD for weekends versus weekdays was 0.7 days; this was not found to be significant (p = 0.189). However, the difference in ALOS between weekend and weekday admissions for those who admitted to GW was 0.3 days, and this was statistically significant (p < 0.001).In terms of model diagnostics, the residuals were fairly normally distributed, with a homogeneous variance. The variance inflation factors for all the variables were below 3, indicating the absence of multi-colinearity.The results from this study confirmed the primary hypothesis that patients admitted on Friday, Saturday or Sunday stayed on average 0.31 days longer than those admitted on weekdays, after adjusting for potential confounders. However, we found that the timing of admission had an even greater effect on length of stay than initially suspected, in that those admitted on the eve of public holidays, and those admitted in the afternoons and after office hours also had a longer LOS . Of particular interest is the fact that the greatest difference in LOS was for those admitted in the afternoons – we could hypothesize that these admission episodes are missing about a day's worth of clinical work-up and management by being admitted past the optimal timing for ordering tests and procedures, which would usually be in the mornings. The above observations are hence consistent with the suspicion of clinical and front-line staff that decreased service levels available after office hours, on weekends, and during public holidays prolong LOS through delays in obtaining the necessary initial work-up for newly admitted cases. Our conclusion is similar to the study done by Iglesia and colleagues [While the effect size reported in our study may appear small, the potential cost savings of successful programs to reduce the length of stay from admission timing should not be underestimated. For instance, if introduction of a staggered work-week could effectively reduce the LOS for the 16,994 admissions on weekends to that observed for admissions on weekdays, we could potentially save 5,207 bed-days, which would then amount to around about S$1.5 million per year in cost-savings in terms of ward-costs alone, assuming an average of S$300 per day . Alternatively, a shift system allowing services to be maintained at the optimal level across a 24-hour day could have an even greater impact, as it would save about 17,600 and 13,900 bed-days in those admitted in the afternoons and after office hours respectively. This may be more difficult to implement than a staggered workweek, but could amount to greater cost-savings in excess of S$9 million per year. Although the premium for maintaining the services around the clock has to be factored into cost-benefit calculations, the above may still be underestimates of the full impact, because appropriate increments in service levels at critical timings would not just reduce LOS in the newly admitted cases, but also in other admission episodes, such as those admitted mid-week but whose stay overlaps into the weekend, for which delays may occur due to the timing-related changes in service levels.With regards to the speciality specific analysis, it was interesting to note the differences observed between General Surgery and Orthopaedics, which are both surgical disciplines admitting acute cases, as well as between Respiratory Medicine and General Medicine, the key admitting disciplines for acute medical cases. While weekend admissions were associated with prolonged LOS for General Surgery, the effect is not borne out for Orthopaedics. One hypothesis could be that admission on a weekend delays key procedures for General Surgery patients, but not for Orthopaedics. Analysing the dates and times of operations in the two disciplines against day of admission could test such a hypothesis. Information on the type and timings of operations performed can also be extracted from routinely available administrative data and linked to admission data. This could be attempted as a follow-up study. The difference in effect between Respiratory Medicine and General Medicine, however, is more difficult to explain. One approach is to compare LOS for similar DRGs across the two disciplines, while adjusting for the potential confounders identified. Such a comparison is possible in Table Based on the existing analysis, we hypothesize that the service levels concerned may be broadly categorized into two types. Firstly, there is decreased medical decision-making capability, both on weekends and after office-hours. For example, ward rounds are not performed on a 24-hour basis, and there is a reduction in the ratio of senior staff to patients on weekends. The other possible bottleneck in service levels would be in the availability of critical support and paramedical services, such as investigations, allied health inputs and inter-disciplinary referrals for key procedures. A recent paper by Bell and Redelmeier  providesOne limitation inherent in our study was the possibility that unmeasured confounders could have affected our results. Since the source of data for this report is primarily from administrative and routine information systems, clinical data that could help us make more detailed inferences was not available. In particular, there could be concerns that the severity of the cases remains an unmeasured confounder in our study. At least two studies have found that more severe cases tend to be admitted more frequently on weekends,8 HoweveWe were able to use routine administrative data to show that weekend admissions, as well as afternoon and after-office hour admissions, are associated with increased LOS at the hospital level. Because we used only routinely available administrative data, the study could be easily replicated in other settings. The information yielded in such analyses could confirm if the effect also exists in other hospitals, help to identify the specialities and disease groupings most affected, and provide the impetus for hospital administrators to invest further resources in identifying factors amenable to organizational changes. We postulate that the factors involve possible bottlenecks in service provision over weekends and after office hours. Further studies, possibly by major disciplines and disease conditions, are needed to identify the processes that constitute these critical bottlenecks.The author(s) declare that they have no competing interests.MIC conceived the study and contributed to the study design, analysis, interpretation and writing of the manuscript. AE contributed to the statistical analysis, interpretation and writing of the manuscript. ES contributed to the interpretation and writing of the manuscript.The pre-publication history for this paper can be accessed here:


Diabetes mellitus is a serious and increasing health problem in Australia and is a designated national health priority. Diabetes and related conditions represent an even greater health burden among Indigenous Australians (Aborigines and Torres Strait Islanders), but there are critical gaps in knowledge relating to the incidence and prevalence, aetiology, and prevention of diabetes in this group, including a lack of information on the burden of disease among Indigenous people in urban areas. The DRUID Study (Diabetes and Related conditions in Urban Indigenous people in the Darwin region) was designed to address this knowledge gap.The study was conducted in a specified geographic area in and around Darwin, Australia. Eligible participants underwent a health examination, including collection of blood and urine samples, clinical and anthropometric measurements, and administration of questionnaires, with an additional assessment for people with diabetes. The study was designed to incorporate local Indigenous leadership, facilitate community engagement, and provide employment and training opportunities for local Indigenous people. A variety of recruitment methods were used. A total of 1,004 eligible people gave consent and provided at least one measurement. When compared with census data for the Indigenous population living in the study area, there was a marked under-representation of males, but no substantial differences in age, place of residence, Indigenous group, or household income. Early participants were more likely than later participants to have previously diagnosed diabetes.Despite lower than anticipated recruitment, this is, to our knowledge, the largest study ever conducted on the health of Indigenous Australians living in urban areas, a group which comprises the majority of Australia's Indigenous population but about whose health and wellbeing relatively little is known. The study is well-placed to provide new information that can be used by policy makers and service providers to improve the delivery of services and programs that affect the health of Indigenous people. It also represents a valuable opportunity to establish an urban Indigenous cohort study, provided participants can be followed successfully over time. Diabetes mellitus, predominantly type 2, is a serious and increasing health problem in Australia and has been designated a national health priority area . AusDiabIndigenous adults aged 25–54 years were hospitalised for diabetes at about 15–18 times the rate for non-Indigenous adults in 2001–02; death rates from diabetes among those aged 35–54 years were 27–35 times higher for Indigenous than non-Indigenous people in 2000–02 [According to an extensive review of diabetes in Aboriginal and Torres Strait Islander populations , there rThe main aims of the DRUID Study were to:• provide the first accurate assessment of the burden of diabetes, diabetic complications and associated chronic diseases in an urban Indigenous population, and to make comparisons with Australian-wide data;• work with an urban Indigenous community to plan, implement and evaluate interventions to reduce the incidence of diabetes among those at high risk;• facilitate contact with, and use of, appropriate services for people with diabetes and related disorders;• increase awareness and understanding of diabetes among Indigenous people in the Darwin region;• facilitate community engagement and provide education, employment and training opportunities for Indigenous people in an urban area;• increase the capacity of Indigenous people to prevent diabetes; and• increase the capacity of Indigenous people with diabetes and related disorders to manage their health in partnership with health service providers.The study was intended to have three parts. The first part was baseline data collection, which combined recruitment and a health examination. This component, which is the subject of this paper, was expected to take approximately one year, but took approximately 50% longer, primarily due to slower than anticipated recruitment, as is discussed in detail below. The second component, a healthy lifestyle intervention among people with impaired glucose tolerance (IGT) and impaired fasting glucose (IFG), was expected to take place in years 2–5 of the study. This component was subsequently cancelled because the lower than expected number of total participants resulted in insufficient numbers of study participants with IFG or IGT. The third component – annual follow-up of participants to collect information on their vital status, incidence of selected major conditions and use of health services – is soon to commence.In addition to undertaking formal data collection activities, it was intended that the study would increase diabetes awareness and provide opportunities for health education and health promotion, both through the provision of results and targeted health information to participating individuals, and through partnerships among researchers, service delivery organisations and advocacy bodies.The study was conducted in and around Darwin, a city of approximately 100,000 people located on the northern coast of Australia. At the time of planning the study, Darwin had a number of characteristics that were expected to greatly enhance the feasibility of the study and the identification, recruitment and follow up of participants, such as: perceived community support for, and potential involvement in, the study; strong and stable family networks; excellent identification of Indigenous people in the relevant administrative collections; a relatively high number of Indigenous people in a relatively small total population; existing partnerships between researchers and health practitioners through the Cooperative Research Centre for Aboriginal Health and other forums; and a pool of local Indigenous people who had research experience and/or could be trained to participate actively in the conduct of the study. In addition, the Darwin Indigenous population was similar to the total Australian Indigenous population on a range of socio-demographic and health risk factor variables, such as unemployment rate, post-school qualifications, household size, proportion of households in rented accommodation, smoking status, and proportion overweight/obese ,7. This Major funding was provided by the National Health and Medical Research Council of Australia (project grant #236207). Supplementary funding was provided by the Vincent Fairfax Family Foundation, the Clive and Vera Ramaciotti Foundation (equipment grant # RA040/03), the Australian Government Department of Employment and Workplace Relations, and the AusDiab Partnership in type 2 diabetes. Several organisations provided in-kind support, as described below.The Study was intended to be run as a partnership involving researchers, health service providers and Indigenous people and organisations. A number of groups were formed to support this partnership approach, including a management group, an Indigenous Steering Group (ISG), a technical reference group (TRG), and the project team. In order to facilitate communication, there was cross-representation across these groups.The management group, comprising investigators and the project manager, had ultimate financial and scientific responsibility for the study overall. The ISG was intended to represent Indigenous groups in the local area and provide leadership and ensure practical benefits to the Indigenous community. Members were primarily Indigenous residents of the Darwin region who had a strong interest in health issues and who saw diabetes as an important issue for themselves, their families and their community. The TRG was intended to provide technical expertise and guidance and contribute to the rigor and efficiency of the study. Most of the work of this group was done in smaller groups on an ad hoc basis. Members included researchers and service providers chosen on the basis of their expertise and interest in the study. The project team was responsible for the day to day management and implementation of the study in keeping with broad directions set by the management group and the ISG.A number of organisations were identified as project partners. These organisations indicated their support for the study and committed themselves to providing direct and/or in-kind support in various ways, including staff time, facilities, expertise and other support, as indicated in table Several other local organisations, such as community organisations, workplaces, and high schools, also made important contributions to the study, most commonly through assisting in recruitment and providing facilities for screening. Bayer HealthCare provided two urinalysis machines and accompanying consumables.DRUID study partners committed to several core principles, including: developing and maintaining trust; Indigenous direction; employment, training and development opportunities for Indigenous people; high quality research methods; a transdisciplinary research focus; openness to working in new and appropriate ways; evaluation; and research transfer.The study was approved by the joint Menzies School of Health Research – Northern Territory Department of Health and Community Services Human Research Ethics Committee. The project was considered and approved by both the Aboriginal sub-committee, which has absolute right of veto, and by the main committee.The study was aimed at adults aged 15 years and over who identified as Aboriginal and/or Torres Strait Islander, had lived within a geographically defined area around Darwin for at least 6 months, and who lived in a private dwelling . The defined area was an administrative region known as the Yilli Rreung Aboriginal and Torres Strait Islander Commission (ATSIC) Region. This region of approximately 10,355 square kilometres is located in the northwest corner of the Northern Territory and includes the cities of Darwin and Palmerston, and a rural hinterland with several small towns and communities.Based on data from the 2001 Census, the estimated resident Indigenous population (ERP) of the Yilli Rreung ATSIC Region as at 1 July 2004 (the approximate mid-point of the recruiting phase) included approximately 12,306 Indigenous people. This ERP figure takes into account adjustments for people whose Indigenous status was not stated, the estimated net census undercount, and births, deaths and migration between the time of the Census and the time of the estimate ,9. Of thOne of the main barriers to the conduct of population-based research in Australian Indigenous communities in urban areas is the lack of a sampling frame from which to select and contact potential participants. Indigenous people are not identified as such in the lists traditionally used in research, such as the electoral roll, telephone listings, etc. Although some existing lists do include Indigenous identification, these are usually incomplete and/or include people from outside the area of interest . In any case, current privacy laws do not generally allow this information to be provided to researchers. In discrete Indigenous communities , it is possible to draw a sample based on total population lists and then exclude the small proportion of non-Indigenous residents. In most urban areas, by contrast, Indigenous people make up a relatively small proportion of the population and they are widely dispersed across the city.Given the absence of a list from which to select a sample of participants, and the apparent support for and interest in the study at the time it was first proposed, it was decided to attempt to recruit as many eligible people as possible. Three main methods of recruiting participants were identified during the initial planning of the study, including: 1) recruiting through the local Aboriginal Health Service; 2) using community and family networks starting with members of the study's ISG and working outward; and 3) contacting people through the Northern Territory Department of Health and Community Services (NTDHCS). A full-time recruitment officer was appointed to assist in developing and implementing these and other complementary strategies.None of the three main recruitment methods was an unqualified success. The Aboriginal Health Service (AHS) was going through a prolonged period of instability, with management problems, financial difficulties  and highThe ISG members were mixed in their ability to recruit participants through their community and family networks. Several members of the group did not themselves participate in the study, while others referred scores of participants. The members of the group, who were acting in a voluntary capacity, are leaders in their communities; as such, they face a large number of competing priorities for their limited time and energy. It is also possible that the long lead time between applying for and receiving funding led to a diminution of the momentum among this group. In any case, it was often difficult to ensure a quorum at ISG meetings once the study was up and running.Contacting potentially eligible people through the NTDHCS was also limited in its success, in large part because of problems relating to out-of-date or incorrect addresses. The NTDHCS maintains a Client-Master Index which includes the name, Indigenous status and last known address of all people who have accessed public health or community services in the Northern Territory; this includes being born in an NT public hospital.  Although study staff could not legally access the Client-Master Index directly, it was agreed that the NTDHCS would send a letter and information packet on behalf of the DRUID Study to all people who appeared to be eligible for the study, based on Indigenous status, age and residential address. Of 8,061 letters sent out by NTDHCS, approximately 2,620 (33%) were returned to sender. Of these, the majority (68%) were reported as having moved. Others were returned to sender due to an unknown or insufficient address (24%), were unclaimed (7%), or the addressee was reported as deceased (2%). It is highly likely that other letters did not reach their intended destination and were destroyed rather than returned, but it is impossible to be certain of the magnitude. Several DRUID staff members who were eligible to participate in the study did not receive one of these letters.A variety of other recruitment strategies was used throughout the study, with varying degrees of success. Some of these were aimed at increasing awareness of the study, while others were aimed at securing actual participation. A logo and slogan were designed, and a community launch was held during the first month of screening, with hundreds of key community members and organisations invited. Information packets were sent to all general medical practitioners and health centres in the area, explaining the study and encouraging them to refer all Indigenous patients. Booths were set up in major shopping centres, health fairs, sporting venues and at community events. Several newspaper ads were placed, especially at the beginning and end of the recruitment period. A television ad was made using a well-known local Indigenous musician. This was run as paid advertising on the main commercial station and as a community service announcement on both local commercial stations. A complementary radio ad campaign was run in conjunction with the television ads. Media releases were prepared to coincide with several events, resulting in stories with photos in several newspapers, as well as television news items and radio interviews. Information was also sent to the newsletters of sporting clubs and associations, employment groups and community organisations.Translating general awareness of the study into either participation or a clear refusal to participate was especially challenging due to the lack of a list of names and contact details. Staff members entered potentially eligible people known to them into a database, but the number of entries fell far short of the estimated number eligible. Attempts were made to contact all those listed in the database by telephone or letter, but many could not be reached. Door-knocking was conducted in the two areas with the highest proportion of Indigenous residents, but this resulted in few completed appointments and was not continued.Greater success was achieved through a series of visits to workplaces, high schools and discrete Indigenous communities, including town camps and small settlements. An estimated 40% or more of all participants were recruited through such visits. Recruitment and screening were conducted at approximately 20 workplaces , five high schools, and nine discrete communities. The NT Public Service Commissioner agreed that eligible staff in NT Government departments could participate in the study during work time without loss of pay; other workplaces appeared to adopt a similar policy. Some supportive individuals took advantage of the study's offer to host family events as part of recruitment. Family members were invited to participate in screening at their relative's house, followed by a barbecue with food supplied by the study.A total of 18 different individuals were employed on contracts over the course of the baseline phase of the study. Of these, 13 were Indigenous and 5 were non-Indigenous. Additional people were employed on a casual basis during visits to discrete communities; these community members acted as local facilitators. An Aboriginal Eye Health Worker from the local Aboriginal Health Service was seconded to the study during follow-up screening among participants with diabetes (approximately 1 day a month). Three post-graduate research students (one of whom is Indigenous) also participated in the study, with one substantially involved in data collection, and the other two participating in a more limited way.All DRUID staff members who had access to data collected in the study were required to sign a confidentiality pledge. This pledge states that the person who signs it is aware of the sensitive and confidential nature of the information, and that he or she understands that inappropriate use of the information will be grounds for immediate disciplinary action, which may include termination of employment. This pledge was based on that used in the Strong Heart Study in the US .A DRUID Study staffing and recruitment strategy was developed in conjunction with the ISG. In addition to traditional recruitment methods such as newspaper advertising, information on the positions available was sent for wide distribution to all ISG members as well as to a number of local community organisations and government departments. Secondments and flexible working arrangements were strongly encouraged, but these were not taken up. ISG members participated in drafting the position descriptions, and every selection panel included at least one member of the ISG.Twelve staff were hired and trained together just prior to the start of data collection. Four staff had previously completed an Aboriginal Health Worker course, one was a nurse, and one had a certificate in laboratory skills. The others came from a variety of non-health backgrounds. With the exception of the project manager, none of the staff had a university degree, and few had completed high school. Only one staff member other than the project manager had previous research experience.Training consisted of both on-the-job and formal training. This began with a one-week structured orientation/induction program including basic training in research methods and in diabetes understanding, followed by one week of specific role-based training. Staff were classified as having clinical, laboratory, interviewer or administrative responsibilities and were provided training relevant to these areas.One of the activities included during the initial training program was the production of a video about the study. This video was used during the consent process and showed potential participants what would be involved, should they choose to take part. The successful production of the video required the actors (DRUID staff members) to learn to perform their study tasks to an adequate standard. This provided incentive to learn the material being presented to them during didactic instruction. During this same time, staff members also participated in discussions about suitable logos and slogans for the study and provided feedback on the data collection forms.Over the course of the study, several staff members were supported to undertake additional training activities. For example, several staff completed a venipuncture certification course , one enrolled in a post-graduate diabetes educator course, another in a Certificate 3 laboratory skills course, and another in undergraduate science units. Staff also attended a local conference on chronic disease as a group. Other informal training, mentoring and support were provided to all staff. Support for many of these additional training activities was provided by the Australian Government Department of Employment and Workplace Relations, through a Structured Training and Employment Project funded as part of the Government's Indigenous Employment Strategy.The original staff members were hired on one-year contracts. This caused difficulty when recruitment was much slower than anticipated, because the contracts could not be shortened or terminated. With the exception of the initial project manager (who decided to pursue a PhD), staff who left the team prior to the expiry of their contracts were not replaced. These departures occurred for a variety of personal, health and performance related reasons.Potential participants were provided with written information about the study, invited to watch a video detailing what was involved, and given an opportunity to ask questions. Those who indicated that they wished to participate were then asked to complete and sign a consent form. A parent or guardian was asked to sign the form as well if the participant was under 18 years old.Participants were asked to give separate consent for various elements of the study, including: questionnaires; fasting blood sample; 2-hour oral glucose tolerance test; urine sample; body measurements; blood pressure; and cardiovascular measurements. They were also asked to indicate the preferred method of contact (telephone or post) for their individual results, and whether they wanted a report sent to a primary health care provider .Participants were requested to select one of three options regarding the long-term storage of excess blood and urine samples: 1) destroy all remaining samples after completion of baseline tests; 2) store any remaining samples, but contact the participant to seek permission if a researcher wishes to use them in the future; 3) store any remaining samples, and use them without contacting the participant, provided their use is approved by the ISG and the relevant ethics committee(s).Permission was also sought to obtain information about participants from other data sources, including: their health care provider(s); pathology services; the NT Department of Health and Community Services ; the Darwin Private Hospital; and the NT Registrar of Births, Deaths and Marriages and the National Death Index. This was necessary because of privacy legislation governing the secondary use of data from these sources.The consent form indicated that study staff would contact participants in future years to update their contact details and to collect limited additional data on health and use of health services. Participants were asked to provide permission to contact their family and/or friends to help us find them in the future. This was intended to reduce suspicion and unwillingness to provide information by indicating the person's wishes to his or her family and friends.We also asked participants whether they would be willing to have the study team contact them in the future: 1) to invite them to participate in a continuation of the current study beyond the initial five years; and 2) to discuss other related studies that have been approved by the study's ISG and by the relevant ethics committees.Participants with diabetes who were invited to participate in additional tests for diabetes complications (described below) were asked to complete a second consent form. This form asked them to agree to participate in the various components of the complications assessment, including an eye examination, foot examination, blood pressure measurements, echocardiograph, and questionnaire. They were also asked to indicate how they wished to receive their results and whether they wanted a report sent to a health care provider .Following confirmation of contact details and eligibility, and after obtaining informed consent, a health examination was undertaken. This examination included: collection of blood and urine samples; clinical and anthropometric measurements; and the administration of questionnaires. The examination required a minimum of 2.5 hours for most participants, and was followed by a light lunch. After the examination was completed, participants were asked to provide contact details for any friends and relatives who might be interested in participating in the study.People with diabetes were invited to return on a later day for additional tests, including examination of the eyes and feet, additional blood pressure measurements, an echocardiograph and additional questions relating to the management and complications of diabetes. This examination took approximately 30–45 minutes.In order to determine the participant's fasting status and whether an oral glucose tolerance test was required, a few screening questions were asked regarding time since the person had last eaten, whether pregnant , and whether currently using insulin and/or tablets for diabetes. Oral glucose tolerance tests were not conducted on pregnant women or those currently using insulin and/or tablets for previously diagnosed diabetes. Those who had not fasted for at least 10 hours were asked to return on another day.For participants who reported fasting for at least 10 hours, a fasting blood sample was drawn, with up to 4 tubes (up to 13 ml) of blood collected. Immediately following this, participants were given a 75 ml glucose drink  unless they were currently taking tablets and/or insulin for previously diagnosed diabetes, were pregnant, or did not consent to this part of the study. A second blood sample (approximately 2 ml) was collected 2 hours later.A urine sample was collected during the visit, at a time of the participant's choosing. Urine samples were sent away for analysis as described below. In addition, local dipstick testing of urine was introduced after the first few months of recruitment to establish whether a urinary tract infection was present at the time of the examination. Dipstick testing was performed using Multistix 10SG multiple reagent strips  and a urine chemistry analyser . Participants with urine that was dipstick-positive for leucocytes, nitrites and/or blood were asked for permission to send a midstream urine sample to a local pathology service for further testing, with results provided to the DRUID study. If positive, both the participant and his or her general medical practitioner were notified. Some participants declined to give permission for further urine testing; they were asked to see their primary health care provider for follow-up.Blood and urine samples were labelled, processed, frozen, and shipped to the Clinical Trials Laboratory at Flinders Medical Centre  for analysis. The instruments and analytical methods used were as shown in table Blood samples were stored on ice until centrifuged. With the exception of HbA1c (for which whole blood was used), all blood and urine was spun by centrifuge at 3000 RPM for 15 minutes. Whenever possible, blood samples were spun within one hour of collection.As part of a sub-study on polycystic ovary syndrome (PCOS), an additional blood sample was collected, generally as part of the fasting sample, for females aged 45 years and under. These samples were processed in the same way as the other blood samples (as described above), but they were sent to the Repromed Laboratories . Details on assays and analytic methods are shown in table Clinical measurements included blood pressure and pulse rate and, for participants aged 25 years and over, an electrocardiogram. Anthropometric measures included height, weight, waist circumference and hip circumference. No anthropometric measurements were taken for participants in wheelchairs, and only height was measured for pregnant women.Blood pressure was measured three times after the participant had been seated quietly for at least 5 minutes. A Welch Allyn Spot Vital Signs monitor  was used to measure systolic and diastolic pressure, with one minute between readings. The pulse rate from the second reading was also recorded. For every twentieth participant, an additional measurement of blood pressure was taken using the auscultatory  technique. For these participants, manual and automatic measurements were done in alternating order.An electrocardiogram (ECG) was performed on participants aged 25 years and over using a Philips PageWriter 10i handheld 12-lead electrocardiograph with automatic interpretation . ECG tracings were evaluated and coded in a single batch by a trained and certified Minnesota coder.Some participants aged between 30 and 60 years were part of a special sub-study involving measurement of carotid intima media thickness using ultrasound, and of arterial stiffness using pulsewave analysis. These methods will be described elsewhere.Height in centimetres was measured using a portable stadiometer . Participants were shoeless and wore light clothing. They were instructed to stand facing forward with weight distributed evenly on both feet, with heels together and against the wall and arms hanging loosely by their sides. The participant's head was positioned so that the Frankfort Plane was horizontal. The participant was then instructed to keep his or her eyes focused on a point straight ahead, breathe in deeply, and stretch to his or her fullest height, with heels still on the ground. The measuring plate was then lowered onto the scalp until it rested firmly on the top of the head and a reading to the nearest 0.1 cm was obtained and recorded. Following the measurement of weight (as described below), a second height measurement was obtained and recorded, again to the nearest 0.1 cm. If the two height measurements differed by more than 0.5 cm, a third measurement was taken and recorded.Weight in kilograms was measured using a Seca digital portable scale . Participants were asked to remove shoes, heavy garments, heavy jewellery, belts, loose change, keys, mobile phones, and other items from pockets. With the scales at zero, participants were asked to stand on the centre of the base with feet together, arms hanging loosely at the sides and the head facing forward. Weight was recorded to the nearest 0.1 kilogram.Waist and hip circumference were measured in centimetres using a 2-metre non-stretch fibreglass tape. Following removal of outer clothing, tight-fitting garments, belts and heavy items from pockets, participants were asked to stand comfortably erect in a relaxed manner, breathing normally, with weight balanced evenly on both feet, feet about 25–30 cm apart, and arms folded across the chest. Waist and hip measurements were taken alternately, with a minimum of two measurements for each. All measurements were taken and recorded to the nearest 0.1 centimetre. If the first two measurements of either waist or hip circumference differed by more than 1.0 cm, then a third measurement was taken for waist or hip, as relevant. Waist measurements were taken directly on the participant's skin if possible, or over at most one layer of clothing. Hip measurements were taken over the participant's clothing, unless it was too tight or too baggy, in which case the participant was asked to remove it.The waist was defined as the midway point between the iliac crest and the costal margin. These two landmarks were identified and marked using a felt tip pen, and the distance between them measured, with the midpoint marked. Once the tape was around the participant's body at the appropriate height and the tape was horizontal, the participant was asked to breathe out gently. The measurement was taken at the end of a normal expiration, with the tape pulled snug but not compressing the underlying soft tissue.The hip circumference was defined as the widest circumference over the buttocks and below the iliac crest. The hip circumference was measured at several positions (starting with the widest part of the buttocks when viewed from the side) and the widest circumference recorded. Fatty aprons were not included in the measurement of the hips. The measurement was taken with the tape in a horizontal position, and the tape was pulled to allow it to maintain its position without causing indentation.Questionnaires covered a range of topics, as indicated in table In response to concerns about slower-than-anticipated recruitment, modifications were made to the questionnaires after the study had been underway for approximately six months. For participants assigned an ID number less than or equal to 400, three questionnaires covered the following areas: 1) General medical history and risk factors; 2) Psychosocial factors; 3) Women's reproductive health . After six months, the first two questionnaires were shortened and combined into one form. The content of the women's reproductive health questionnaire was unchanged, but administration was limited to women aged 45 years and under.Approximately 40% of Questionnaire 1 (Version 1) and Questionnaire 2 (Version 1) were self-administered. This increased to 91% of the combined Version 2 Questionnaire. About 79% of women's reproductive health questionnaires were self-administered.Participants with diabetes, either previously known or newly diagnosed through the study, were invited back for an additional set of tests relating to diabetes complications. For the purposes of this study, a participant was considered to have diabetes if: a) he or she reported a previous physician diagnosis of diabetes and was currently taking tablets and/or insulin; or b) his or her blood test results indicated glucose levels consistent with diabetes .Diabetes complications screening sessions were held approximately every other month. Some participants attended the first session following their initial health examination, others attended only after several months of broken appointments and numerous reminder calls, and some declined to participate in this part of the study.The complications assessment consisted of a questionnaire, a clinical examination, and an eye examination. The questionnaire covered the following topics: age at diagnosis, diabetes care provider, history of amputations, history of foot ulcers, signs and symptoms in the legs and feet . Reflexes were classified as normal, present with reinforcement or absent.Vibration perception (on the great toes) and temperature perception  were assessed using a standard 128 Hz tuning fork. Pin-prick perception was assessed on the dorsal surface of the great toes using a sterile neurological examination pin . Participants were tested with their eyes closed.Pressure perception threshold was measured using a 10 g monofilament at the great toe, first metatarsal head and fifth metatarsal head on the plantar surface of each foot. Participants were tested with their eyes closed. The order of sites was varied from participant to participant.Lying and standing blood pressure were measured using a manual anaeroid sphygmomanometer . Systolic and diastolic pressures were measured at the brachial artery in the right arm while the participant was in a supine position, after lying down for at least 5 minutes. The measurements were repeated one minute after standing.Ankle brachial pressure index was measured with the participant in a supine position. Systolic arm pressure was measured at the brachial artery using a Doppler probe  and an anaeroid sphygmomanometer . This was followed by Doppler measurement at the dorsalis pedis or posterior tibial artery of the foot.The eye examination included measurement of visual acuity and digital retinal photography. Visual acuity was measured using a standard 6-metre wall-mounted Snellen eye chart . Participants were tested as they presented, i.e. wearing their glasses or contact lenses if they wore them to the testing site. Pinhole testing was performed for those whose presenting visual acuity was worse than 6/6, but who were able to at least count fingers. Digital retinal photographs were taken by a trained Aboriginal Eye Health Worker using a Topcon non-mydriatic retinal camera . Photographs were taken in two fields per eye . In some cases, eye drops were required to dilate pupils in order to obtain a good image; this was noted. Photographs were graded by a single ophthalmologist at the Centre for Eye Research Australia . If photos could not be obtained , the participant was asked to provide consent for the study team to obtain recent results from the relevant eye care provider.An echocardiogram was performed as part of a sub-study on selected participants aged between 25 and 64 years old. The methods will be described elsewhere. Measurement of urinary albumin-creatinine ratio (ACR) and glycated haemoglobin were performed during the initial stage of the study; most participants with diabetes also underwent an ECG, as they were 25 years or older. These tests and measurements were not repeated during the second visit.The provision of individual results was an important part of the study's relationship with the community. Some feedback was provided at the time of testing, and some participants, such as those with very high blood pressure or with chest pains plus an abnormal ECG, were referred immediately to the appropriate health care provider. DRUID clinical staff also maintained a list of primary care providers for participants who reported that they did not have a usual care provider. Before the first individual results were sent, all local medical practitioners identified by the Top End Division of General Practice were provided with information on what the reports would contain, as well as information on when, how and where to refer patients with abnormal results and how to use relevant Medicare item numbers. This information was designed with the assistance and input of local medical specialists.A packet containing individual results was provided to each participant once his or her blood and urine results were received from the Clinical Trials Laboratory. Participants received their own values for height, weight, body mass index, waist circumference, self-reported smoking status, blood pressure, total cholesterol, triglycerides, HDL cholesterol, urine ACR, glomerular filtration rate (GFR), and fasting and two hour glucose values (and HbA1c for people with previously diagnosed diabetes), along with a description of what the test or measurement indicated, the range of normal values and a comment on their own scores. Participants also received health education materials tailored to their specific results. With the participant's consent, a report was also sent to the person's primary health care provider. Whenever possible, participants with abnormal results were first contacted by telephone or in person. The results packet was then mailed or hand-delivered, as appropriate. Some results were not able to be delivered because the participant had moved or could otherwise not be located.People who participated in the assessment of diabetes complications were provided with information about their foot examination on the day of testing. They also received information about diabetes and its complications from staff, including an endocrinologist specialising in diabetes and a diabetes educator. Participants received a letter indicating their eye results once the grading of retinal photographs was completed. With the participant's consent, a report on the complications assessment was sent to the participant's primary care provider and/or diabetes care provider. This report included information on foot ulcers, amputations, pressure perception threshold test, ankle brachial pressure index, urine ACR and GFR , visual acuity, and retinopathy grading.Information about potential participants was entered into specially modified business contact tracing software . Although it was intended to use this software for all appointment booking, recruitment activities and participant contact, the relative lack of intermediate-level computing skills within the team meant that the potential of this system was not fully realised.® version 5.5 software  and a high-speed duplex colour image scanner . Blood and urine results and retinal grading were provided by the relevant laboratory in spreadsheets and uploaded directly to the Oracle database. All data will be subjected to a range of assessments relating to completeness, accuracy, and plausibility. Once these checks have been completed, a final data set will be created.All data other than name and contact details were entered, using a combination of manual entry and optical scanning, into a custom-designed Oracle database  with a Microsoft Access front end. Anthropometric and clinical measurements were entered manually from the relevant recording form, as were responses to all questions on the consent forms. All questionnaires were scanned using Remark Office OMRAll statistical analysis will be performed using the latest available release of Stata software . Techniques will vary according to the specific analysis, but will primarily involve multivariate linear or logistic regression.Between 12 September 2003 and 31 March 2005, a total of 1,033 Indigenous residents of the Yilli Rreung ATSIC Region completed a consent form. Twenty-four of these participants were ineligible due to length of residency or age and were excluded from further consideration: 16 indicated that they had lived in the area for less than 6 months, and a further 8 high school students had not yet turned 15 years old. Study staff also tested 7 Indigenous people who were not residents of Yilli Rreung and 28 non-Indigenous volunteers . The tests of people known to be ineligible were done in certain circumstances to promote a positive image of the study and to increase awareness of diabetes.Of the 1,009 eligible participants who gave consent, 1,004 provided at least one measurement. The numbers of eligible participants who provided selected information was as follows: consent – 1,009; fasting blood sample – 945; oral glucose tolerance test – 815; urine sample – 910; questionnaire 1 (version 1 or 2) – 920; questionnaire 2 (version 1) – 312; women's reproductive health questionnaire – 441 (women aged 45 years and under); blood pressure – 996; height – 969; weight – 965; waist circumference – 938; and hip circumference – 935. Of the 175 participants eligible for complications assessment, 138 were examined.The 1,009 eligible people who completed a consent form represent approximately 14.3% of the estimated 7,051 people who were potentially eligible as at 1 July 2004 (the approximate midpoint of the recruitment period). Information on sex, age group, area of residence, Indigenous status and household income was compared for DRUID participants and for Yilli Rreung residents, based on data from the 2001 Census and from the NTDHCS Client-Master Index. This is presented in the following figures.As shown in figure The age distribution was also significantly different in the DRUID Study than in the Yilli Rreung population in 2004 (p < 0.001) or the NTDHCS Client-Master Index (p < 0.001), with fewer than expected participants in the younger age groups figure , and wasThe distribution by place of residence was similar for DRUID Study participants and the Yilli Rreung Indigenous ERP figure , althougThe proportion of DRUID participants reporting sole Aboriginal identification was slightly lower than in the Yilli Rreung ERP, while the proportion reporting mixed  origin was higher figure . AlthougThe distribution of weekly household income was also significantly different (p = 0.002), but not in any systematic way figure . Some ofIt is not possible to know whether the health status of DRUID Study participants was different from that of non-participants. There is some evidence to suggest that the health status of participants varied over the course of the study, with early participants significantly more likely (p = 0.001) to report previously diagnosed diabetes figure . This isAs shown in figures The proportion of participants who reported they were current smokers was high as expected, and did not vary significantly over the course of the study  for earlier and later participants figure , but thePopulation health research involving Indigenous Australians has long been a challenging endeavour -20, and Our success in meeting our aim of providing the first accurate assessment of the burden of diabetes, diabetic complications and associated chronic diseases in an urban Indigenous population depends on how well the study participants represent the population of interest. Participants were not substantially different from the population of interest with respect to demographic features other than sex. Although there were statistically significant differences between study participants and the Yilli Rreung Indigenous estimated resident population in the distributions by age, sex, area of residence, Indigenous group and household income, these differences were small in absolute terms, with the notable exception of sex. In addition, the Yilli Rreung ERP includes people living in non-private dwellings, who were not eligible to participate in the study. This inclusion may explain some of the differences in the distributions between the two groups. In any case, it highlights the importance of using caution when interpreting such comparisons. The Australian Bureau of Statistics (ABS) does not produce a separate ERP figure for the Indigenous population in private dwellings, so the only other option using ABS data is to use census counts of people in private dwellings as the basis of comparison. However, unlike the ERP figures, these counts do not take into account people who were not included in the Census or who did not respond to the question on Indigenous status, and the figures are only available for years in which a census was conducted. As with the ERP, these factors could have an impact on the distributions of interest. Comparisons using the NTDHCS Client-Master Index must also be made with caution, given the high rate of letters returned to sender, and the fact that several eligible staff members did not receive a letter.The representativeness of the health status of participants is unknown. Early participants were clearly more likely than later participants to have a history of chronic health problems, such as a previous diagnosis of diabetes and hypertension. However, after the first 200 participants, the rates generally stabilised, which may indicate that participation was independent of health status during most of the study. In addition, the proportion of participants who reported they were current smokers was stable throughout the study, which does not suggest any difference in health risk factor profiles, at least for one important health behaviour.Although the disease prevalences observed in the study can not be interpreted as true population prevalences, they may still provide useful – albeit approximate and possibly somewhat biased – estimates. In any case, few alternative estimates are currently available for any urban Indigenous populations in Australia, and none exist for the Darwin region. Perhaps more importantly, the extensive data collected in the study will also be used to examine relationships among variables of interest. These data will provide information that is not currently available, and that can be used by policy makers and services providers to improve the services and programs that affect the health of Indigenous people.The second aim of the study – to work with an urban Indigenous community to plan, implement and evaluate interventions to reduce the incidence of diabetes among those at high risk – was not able to be met due to inadequate numbers of participants with impaired fasting glucose and impaired glucose tolerance. This was a function of smaller than expected numbers of participants overall, rather than a lower than expected prevalence of IFG and IGT. In any case, the proposed intervention would have had inadequate power to detect important differences. It was therefore cancelled, with the relevant funds returned to the National Health and Medical Research Council.We had greater success in relation to our other aims, although this is not always easy to demonstrate. The provision of individual results and advice and education materials to participants as well as interaction with staff members is likely to have increased awareness and understanding of diabetes among participants, although this has not been formally assessed. We were clearly able to provide employment and training opportunities for Indigenous people, with 13 Indigenous staff members over the course of the study, but facilitating community engagement proved an ongoing challenge. By engaging health service providers and referring participants with specific health problems to relevant services, we facilitated contact with, and use of, appropriate services for people with diabetes and related conditions. It is difficult at this point to determine the extent to which the study has contributed to achieving our longer term aims of increasing the capacity of Indigenous people to prevent diabetes and increasing the capacity of Indigenous people with diabetes and related disorders to manage their health in partnership with health service providers. Although there have been reports of some participants having adopted healthier lifestyles, and of people with diabetes becoming more involved in their health care following participation in the study, it is not clear how widespread this has been, nor whether any such changes have been maintained.Despite the difficulties encountered in undertaking the DRUID Study, and our inability to achieve all of our original aims, the study was certainly not without its successes. We recruited over 1,000 participants, of whom approximately 94% provided a fasting blood sample. To our knowledge, this is the largest study ever conducted on the health of urban Indigenous Australians. As such it provides a valuable opportunity to establish a cohort study, providing enough participants can be contacted and followed over time. This will be assessed in the next phase of the study, which involves annual follow-up of participants to collect information on their vital status, incidence of selected major conditions and use of health services. If most participants can be traced and contacted, we will continue to follow the cohort over time, with a view to repeat examinations in the future. This would allow estimates of the incidence of diabetes and related conditions to be made, as well as enable a better understanding of changes over time. It would also see the original vision of the study achieved and would add exponentially to its value.ABS Australian Bureau of StatisticsACR albumin-creatinine ratioAHS Aboriginal Health ServiceATSIC Aboriginal and Torres Strait Islander CommissionDRUID Diabetes and Related disorders in Urban Indigenous people in the Darwin regionECG electrocardiogramERP estimated resident populationGFR glomerular filtration rateHbA1c glycosylated hemoglobinHDL high density lipoproteinID identificationIFG impaired fasting glucoseIGT impaired glucose toleranceISG Indigenous Steering GroupNT Northern TerritoryNTDHCS Northern Territory Department of Health and Community ServicesPCOS polycystic ovary syndromeRPM revolutions per minuteTRG Technical Reference GroupThe author(s) declare that they have no competing interests.JC participated in the design of the study protocol, coordinated data collection and data management, analysed the data and drafted the manuscript. KO and PZ conceived of the study and participated in its design. TD chaired the study's Indigenous Steering Group, participated in the design of the study and facilitated Indigenous community input throughout the study. TW participated in the design of the study and provided clinical expertise during the design and data collection phases. JS participated in the study design and was responsible for the development of the diabetes complications assessment component. All authors were involved in revising the manuscript for important intellectual content and read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


The effects of different doses of angiotensin II . Spatial heterogeneity of blood flow within tumours, before and after angiotensin II infusion, was also measured using 14C-IAP and an autoradiographic procedure. Mean arterial blood pressure rose steeply with angiotensin II dose. Blood flow to skeletal muscle, skin overlying the tumour, contralateral skin, small intestine and kidney tended to decline in a dose-dependent manner. Blood flow to the tumour was also reduced  but there was no dose response. Blood flow to the heart was slightly increased and blood flow to the brain was unaffected by angiotensin II. Vascular resistance, in all tissues, was increased by angiotensin II infusion. The increase in tumour tissue was similar to that found in skeletal muscle and small intestine and is likely to be caused by a direct vasoconstricting effect of the drug rather than autoregulation of tumour blood flow in the face of an increase in perfusion pressure. The reduction in overall blood flow at the highest perfusion pressure was due to a preferential effect of angiotensin II at the tumour periphery. These results show that some tumours, at least, can respond directly to the effects of vasoactive agents.


Although health equity issues at regional, national and international levels are receiving increasing attention, health equity issues at the local level have been virtually overlooked. Here, we describe here a comprehensive equity assessment carried out by the Hôpital Albert Schweitzer-Haiti (HAS) in 2003. HAS has been operating health and development programs in the Artibonite Valley of Haiti for 50 years.We reviewed all available information arising from a comprehensive evaluation of the programs of HAS carried out in 1999 and 2000. As part of this evaluation, two demographic and health surveys were carried out. We carried out exit interviews with clients receiving primary health care, observations within health facilities, interviews with households related to quality of care, and focus group discussions with community-based health workers. A special study was carried out in 2003 to assess factors determining the use of prenatal care services. Finally, selected findings were obtained from the HAS information system.We found markedly reduced access to health services in the peripheral mountainous areas compared to the central plains. The quality of services was more deficient and the coverage of key services was lower in the mountains. Finally, health status, as measured by under-five mortality rates and levels of childhood malnutrition, was also worse in the mountains.These findings indicate that local health programs need to give attention to monitoring the health status as well as the quality and coverage of basic services among marginalized groups within the program service area. Health inequities will not be overcome until such monitoring occurs and leaders of health programs ensure that inequities identified are addressed in the local programming of activities. It is quite likely that, within relatively small geographic areas in resource-poor settings around the world, similar, if not even greater, levels of health inequities exist. These inequities need to be measured and addressed in order for health programs to achieve equity and maximum improvement in health status within the population. Issues of inequities in health have received increased attention in recent years. Many discussions of health equity focus on the disparities of health program inputs such as staff and services relative to need, all of which are avoidable and therefore unjust -6. To a In an equitable system, those individuals with the poorest health status should receive more health care and other services to address their greater need. The increased attention now being given to reducing health inequities arises from the obvious fact that, even though the opportunity to be healthy is a basic and universal human right, health systems are failing to reach the poorest of the poor, health disparities are increasing, and the opportunity for a healthy life is denied to billions of people around the world -11.The challenge of addressing health inequities is especially great for developing nations whose limited resources and inadequate data collection systems create large hurdles for establishing effective interventions aimed at reducing inequities. Haiti, for instance, is the most underdeveloped nation in the Western hemisphere, with a per capita GNP of only US$415  and an infant mortality rate of 79 per 1000 live births  . LikewisWide disparities in health status exist within the borders of Haiti as well. Rural areas of Haiti, and particularly mountainous zones with Haiti, have poorer quality of health  and less access to care. It is estimated that 40% of persons living in rural areas of Haiti have no access to any primary health care services. Likewise, these populations have lower rates of child immunizations and lower rates of prenatal care .Much attention has been directed at global -16 and nThe Hôpital Albert Schweitzer-Haiti (HAS), based in Deschapelles, Haiti Figure , has beeUnite Communale de Sante, hereafter referred to as the UCS District) of Petite Riviere, Verettes and LaChapelle. The UCS District had at that time a total of 258,000 residents in 14 Functional Units. The HAS Hospital serves as the referral center for the entire UCS District  in seven Functional Units of the Health District , one for every 15 households, who were providing peer-to-peer health education, assisting with referral to higher levels of care, and promoting community involvement in planning, implementation and evaluation of services;• 1,500 Matwons  who received training in safe delivery and supervisory support from HAS;• 200 Agents de Sante , one for approximately every 400 households, who made regular home visits and directed monthly Rally Posts for immunization, growth monitoring/nutritional counseling, and referral;• 75 Monitrices (Monitors), who provided liaison with and training of Matwons and Animatrices and who supervised the community-based nutritional rehabilitation program;• 8 Auxiliare (auxiliary nurse) visited isolated communities every 1–2 months to provide basic curative and family planning services and to refer patients when indicated; and,• Mobile clinics at which an • 7 fixed primary health care facilities , where curative care, immunizations and family planning services were provided.Prenatal care and family planning services were free and available at Mobile Clinics, Health Centers, and in the Hospital Outpatient Clinic.Accompagnateurs who were working throughout the UCS District.HAS also was operating a comprehensive program of tuberculosis detection and treatment, with over 400 patients entering treatment annually and only 7% failing to complete their entire course of treatment. The initial two months of treatment were provided at a residential facility in Deschapelles, and the follow-up treatment was provided at home through a directly observed treatment-short course (DOTS) program carried out by 12 The HAS Hospital had 190 beds at that time and an active outpatient clinic, providing specialty referral care in adult medicine, pediatrics, obstetrics-gynecology, and surgery for patients within the UCS District and beyond. The health care system facilitated referral of patients to a higher point of care within the district and counter-referral down to lower levels as appropriate. Care was decentralized as much as possible and was designed with the goal of providing Rally Posts within a 30-minute walk of all households and Mobile Clinics with a one-hour walk. Even so, much of the population, particularly that segment living in the mountains, was more than three hours from a Dispensary or Health Center and even further away from the HAS Hospital.At the time of the study, HAS was serving a population that was similar to the rest of Haiti in socio-economic terms. The coverage of key child survival services was considerably higher for the HAS service population than for the rest of Haiti, and under-five mortality had been at least half that compared to the rest of Haiti for the three previous decades ,33. The This article describes the findings arising from a comparison between the peripheral mountainous areas and the more central plains regarding access to, quality of, and coverage of health services and also regarding levels of childhood malnutrition and mortality within a well-developed and relatively high-quality health system as it existed during the period 2000–2003. We define health inequities here as "differences [in health] which are unnecessary and avoidable but, in addition, are also considered unfair and unjust .In 1999 and 2000, the Board of Directors at HAS mandated a comprehensive evaluation of all programs at HAS. The data used in this analysis arose from five different studies that HAS and collaborating organizations carried out as part of that evaluation  In 1999 and 2000, HAS staff carried out a household survey of 3,427 women of reproductive age in the HAS Primary Health Care Service Area and obtained a history from them regarding all births and subsequent mortality of live-born children. These women represented a 10 percent sample of the women of reproductive age. The pregnancy history survey identified 149 deaths of children less than five years of age during the previous five years.(2) In the year 2000, a Haitian health research organization  conducted a household survey of the UCS District concerning a broad set of health and development issues. This survey included 1,310 household heads, 1,295 women of reproductive age, 945 mothers/guardians of at least one child 0–59 months of age, and 1,363 men 15–54 years of age. The households were selected in such a way that ensured adequate representation of both the mountainous and non-mountainous areas of the UCS District as well as of both the HAS Primary Health Care Service Area and the other seven Functional Units in the District. Here, we report findings from the HAS Primary Health Care Service Area only.(3) In 2000, a study was carried out regarding the quality of services provided by the Community Health Division at HAS. This assessment involved exit interviews with caretakers at the time of 108 visits of children to health facilities and with 98 women patients at time of visits for prenatal care or family planning. Observations of encounters in the health facilities were carried out and health staff members at these facilities were interviewed. Also included were 190 household interviews and three focus group discussions with a total of 42 Health Agents. These households and Health Agents were not randomly selected.(4) In 2003, a study was conducted to determine factors affecting the use of prenatal care. In this(5) The HAS information systems were used to calculate the per capita utilization of inpatient hospital services by Functional Unit.Mortality rates were calculated by dividing the number of deaths in the appropriate age group by the number of live births during the same time period and multiplying by 1,000. Exact Fisher 95 percent confidence intervals were calculated according to the methods developed by Fleiss  (1981) uAmong a convenience sample of 190 households in three Functional Units, a marked difference was observed in the frequency of home visits by Health Agents depending on whether they were working in the plains or in the mountains. In the Liancourt Functional Unit (in the plains), only 11 percent of the households reported that their Health Agent made fewer than five visits during the previous 12 months, while in the predominantly mountainous areas of Bastien and Plassac, 37 percent of households reported fewer than five visits.In one Functional Unit (Plassac) in which both mountainous and non-mountainous communities were present, only 38% of the communities in the mountainous areas had a Mobile Clinic coming to the community compared to 98% of the non-mountainous communities, even though the walking distance to the Health Center was at least three hours for 60% of those living in mountainous communities while none of the communities in the plains were that far away. However, none of the pregnant women living in the plains in Plassac used a Mobile Clinic for their source of prenatal care compared to 18% of the pregnant women living in the mountainous communities. Living at least three hours walking time from the Health Center was significantly associated with lack of access to prenatal care , both in a bivariate as well as in a multivariate analysis .The assessment of the quality of care provided at Dispensaries and Health Centers showed deficiencies, and these were more pronounced in the mountainous Functional Units. Family planning was not a frequent topic with patients at the time of prenatal visits. Counseling for breastfeeding as part of the prenatal visit was also infrequent. Overall, fewer than half of the women interviewed who had obtained prenatal care were given advice regarding breastfeeding.Health Agents had not been trained to target men along with women in helping couples to make a joint and informed choice of family planning methods. HAS was not able to offer a broad choice of readily available family planning methods in the mountainous areas since intra-uterine devices and tubal ligation were available only in the Hospital.Growth cards for monitoring the nutritional status of children were often incorrectly filled out. Childhood diarrhea was one of the major reasons for health facility utilization and, according to focus group discussions with Health Agents, diarrhea was the leading cause of childhood illness. Although mothers had been taught how to prepare and use oral rehydration fluid at home, more serious cases required treatment at a health facility. However, there was no provision for mothers to begin immediately rehydrating their child with diarrhea upon arrival at a Dispensary or Health Center, and the waiting time was as long as five hours.Mothers in mountainous areas frequently reported that they were not feeding colostrum to their newborns, that they were weaning their children before two years of age, and that they were not feeding their children frequently. Hand washing with soap was often not practiced.Immunization coverage of both children and women of reproductive age was significantly lower in the mountains than in the plains as was the contraceptive prevalence rate Table The rate of admission of patients to the HAS Hospital according to the Functional Unit in which the patient was living varied substantially according to the distance from the Hospital. The Functional Units closest to the Hospital  had admission rates of 6.4 admissions per 1,000 population per year, compared to rates of less than half that in the other four Functional Units Table . The GabThe prevalence of moderate or severe malnutrition  was more than twice as great in the mountainous areas as in the plains Table .The overall mortality among children aged less than five years in populations of the predominantly mountainous Functional Units was almost twice that for those in the plains: the 0–4-year mortality rate was 90.7 per 1,000 live births in the mountains and 49.8 in the plains Table .The total fertility rate was 1.7 times greater in the Functional Units located in the mountainous areas than in the Functional Units located in the plains (6.8 versus 4.1).The mountainous population is socio-economically different from the population living in the valley area. While many statistics could be cited to characterize this difference, the different level of literacy is perhaps as notable as any. In the mountains, the level of illiteracy is twice as great as in the plains (70.9% versus 38.3%). The percentage of homes in the mountains with no electricity, with no latrine or indoor sanitation, and with no access to a protected source of water is also notably higher than among the homes in the plains Table .There are probably few health and development programs in the world that have given more long-term emphasis on reaching the entire service population with basic services than HAS. Nonetheless, in spite of HAS's long-standing commitment to equity, marked socio-geographic differences in program inputs, access to services, utilization of services, coverage of services, and health status persist within the same relatively small service area (approximately 18 miles by 18 miles) administered by a single health program.Over the past four decades, HAS has made it a priority to provide a similar level of intensity of primary health care services in the mountainous areas as in the valley plains. However, these data indicate that similar levels of inputs have not been successful in achieving health equity within the HAS service area. This is because the health needs are greater in the mountainous areas, and the inputs required to achieve the same health outcomes in the mountainous areas are much greater not only because of the greater health needs but because the difficulties of program operations are much greater .The monitoring and evaluation system had not been designed previously to detect these disparities. While the leadership and staff of HAS noted that the results of the study affirmed their earlier concerns about possible health inequities between those living in the mountains and those living in the plains and continued their efforts to adapt programs to emerging needs.There were a similar number of Health Agents (who make routine home visits) per population throughout the HAS service area even though in the mountainous areas, the health needs were greater, the distances between houses were greater, and the climbing of steep hills and mountains were required in order to reach all homes. All households were supposed to be visited every two months. Since the same number of Health Agents per population existed in the isolated mountainous areas as in the plains, then it was not surprising that there were fewer visits per household per year in the mountainous areas because of the considerable longer distances between houses and the steep climbs that were required while carrying equipment and materials for weighing children and dispensing vaccines.In theory, the provision of Mobile Clinics was supposed to be concentrated in the most distant areas where the travel time to a Dispensary or Health Center was two or more hours. In practice though, this was unfortunately not the case.The HAS Hospital has had a long-standing policy not to turn away patients with life-threatening illnesses because of inability to pay. Elective surgical procedures, however, required pre-payment, although the fees were among the lowest charged in Haiti. The Hospital did not operate a transportation system or ambulance service, and patients were expected to provide their own transport to the Hospital. Obviously, the need for hospital services was just as great (if not greater) in the mountainous areas as in the plains, but per capita hospital utilization by those living in the mountains was in fact only half that by those living in the plains.One commonly cited reason among patients in the mountains for not accepting referral for hospitalization was that they said they cannot afford even the cost of transportation to get there . Presumably, with their lower educational levels, mountain people did not possess the same level of understanding about what the HAS Hospital could do to assist them when certain types of illnesses and conditions arose. Or, perhaps they did not want to risk dying in a distant, unfamiliar place away from family and friends. Here is an opportunity for increasing the flow of information to the people in the mountains.Animatrices in the mountainous areas and increasing the number of Health Agents in the mountainous areas. Previously, while each Animatrice had been assigned to 15 households, there had not been a close monitoring of their work by the Health Agents. For many years until the Animatrice program emerged, the Health Agents had been the prime home visitors, at which time they collected relevant data to be forwarded to the information system. But it became clear that they were unable to fulfill those expectations, to a large extent because of the extreme difficulties of coping with the rough mountainous terrain and geographical dispersion of the families.Obvious initial steps for reducing the disparity in access to basic services included providing more training and support to the Animatrices became the primary home visitors and the Health Agents gave more attention to supervising the work of the Animatrices. The Animatrices were distinctly interested in taking on these additional responsibilities and were proud to be considered for such roles.Following the equity review in 2003, HAS changed the roles and interactive relationships in such a way that the Animatrices of their findings and actions in relation to their home visiting. The capabilities of the Animatrices for reporting, despite their high rates of illiteracy, were to be enhanced by both training and providing them with reporting charts that included artistic illustrations of various health conditions – diarrhea, respiratory infections, use of family planning, injuries, and more – that the Animatrices could complete by making a simple "check" mark. Thus, every household could be visited on a monthly or bimonthly basis with reporting to Health Agents through this simple report form. This home visiting and reporting process, including its supervision, was to be included in the information system. Further, it was envisioned that periodic group discussions among the Animatrices and Health Agents, including the community at times, would add to the oversight capacities of the system.A key new responsibility was to be the reporting by the A further concern emerging from this equity review was the high rate of illiteracy and malnutrition in the mountains, which were seen as principle underlying causative factors for the higher child mortality there. A major nutrition initiative, which also included literacy training for mothers, began soon after this equity review, and this initiative gave priority to people living in mountainous areas. Future assessments will be required to determine to how effective these new activities have been in reducing health disparities.These data provide compelling evidence that, from the standpoint of equity ("to each according to his or her need"), more intense services to mothers and children in the mountainous areas are required, with a particular focus on reducing malnutrition and improving access to hospital care for sick children when needed. The contribution of higher fertility to higher infant and child mortality has been well documented . The higHAS has recently undertaken major revisions in its organizational, financial and service components, in large part due to reductions in funding available to the institution. Even though the resources required to fully address the inequities identified in this study remain insufficient, there is nonetheless a clear and continuing commitment of the institution's leadership to the pursuit of equity and to the equity-related concepts and processes described in this paper.There are at least three rationales for addressing issues of health inequities at the local level. First, ethics demands it. Distributive justice requires special concern for those who are worst off or most disadvantaged .Secondly, if a health program is serious about improving the health of the population it serves, it becomes obvious that the best way to achieve this is by putting more resources into those segments of the population where the prevalence of disease and death are the highest, since improvements in health in this segment of the population will lead to greater improvements in the health of the entire population than would an investment which is equally spread across the entire population.Thirdly, the magnitude of the health gap is often a major rather than a minor one. In many developing countries around the world, differences in under-five mortality between rich and poor households are unacceptably high and, in some areas, are becoming wider . MothersExperience and evidence about how to reduce inequities among the poor segments of populations are growing . SuccessRegular monitoring of inequities and using the resulting information for education, advocacy, and increased accountability among the poorest and most marginalized persons in the service area are urgently needed. Equity must be a priority in the design of health delivery strategies, and mechanisms must exist to ensure accountability at local, national and international levels for addressing and reducing inequities.The levels of inequities observed at HAS are substantial, and they are within a single small geographic area served by a single, relatively well-developed health program committed to equity for more than 50 years. Thus, these findings suggest that health inequities might be even more substantial in geographic areas in poor countries where there are less well-developed health systems and where the same commitment to equity does not exist. Monitoring of equity and reducing inequity should become priorities for local health programs .We have demonstrated marked health inequities within a local population which had ready access to a well-developed health care program with relatively high utilization, high coverage of services, substantial childhood mortality impact, and a long-term commitment to equity. Even within such a relatively well-designed and well-administered comprehensive health system, a monitoring system is needed to detect inequities in access to and coverage of health services, not to mention inequities in health status. Given that health is a basic human right, equity in health should have "pride of place" . Health HAS Hôpital Albert SchweitzerUnite Communale de Sante UCS The author(s) declare that they have no competing interests.HP conceived of the idea for this paper, assisted in the collection of some of the data, participated in some of the data analysis, and contributed to the writing of the paper.LK-S performed a literature review of equity issues, collected and analyzed the data pertaining to prenatal care utilization, and helped to draft the manuscript. AA collected and analyzed some of the data cited here and helped to draft the manuscript. JB provided guidance in the conceptual framework used here, provided encouragement at all stages of this project, and helped to draft the manuscript. All authors read and approved the final manuscript.