There is a paucity of research about health-related quality of life (HRQL) among adolescents, as studies have to a large extent focused on adults. The main aim was to provide information for future studies in this growing field by presenting normative data for the Short Form 36 (SF-36) and the Hospital Anxiety and Depression Scale (HADS) for Swedish adolescents and young adults. Additionally, the influence of age and gender, as well as method of administration, was investigated.A sample of 585 persons aged 13–23 was randomly chosen from the general population, and stratified regarding age group  and gender . Within each stratum, the participants were randomized according to two modes of administration, telephone interview and postal questionnaire, and asked to complete the SF-36 and the HADS. Descriptive statistics are presented by survey mode, gender, and age group. A gender comparison was made by independent t-test; and one-way ANOVA was conducted to evaluate age differences.Effects of age and gender were found: males reported better health-related quality of life than females, and the young adolescents (13–15 years old) reported better HRQL than the two older age groups. The older participants (16–23 years old) reported higher scores when interviewed over the telephone than when they answered a postal questionnaire, a difference which was more marked among females. Interestingly, the 13–15-year-olds did not react to the mode of administration to the same extent.The importance of taking age, gender, and method of administration into consideration, both when planning studies and when comparing results from different groups, studies, or over time, is stressed. Increasingly, the concept "health-related quality of life" (HRQL) has attracted attention in research within the medical and caring sciences . There aResearch has shown that the administration methods influence the way people respond to health status measures. People tend to rate their health and well-being, measured by the SF-36, significantly more favourable in telephone interviews than in questionnaires distributed by mail ,11. One Additionally, demographic variables such as age and gender have been reported as being of importance, both for HRQL in general , and forRegarding the SF-36, normative values for the Swedish population are in existence, reported in the Swedish SF-36 Manual and Interpretation Guide . The youNo previous study has investigated the effect of method of administration, age, and gender on how adolescents and young adults rate HRQL, anxiety, and depression. The main aim of this study is to provide normative data for the SF-36 and the HADS for adolescents and young adults in the Swedish general population (aged 13–23), taking these three factors into consideration. Norms will be presented by method of administration – telephone interview and postal questionnaire – and the potential effect of survey mode will be examined. Additionally, whether gender and age influence the scores on the SF-36 and the HADS will be explored, by survey mode.The sample was randomly chosen by Statistics Sweden from their register of the total population. The target population included all individuals covered by civil registration between 13 and 23 years of age, living in three public healthcare regions in Sweden: South, Uppsala/Örebro (Middle) and North. These areas were chosen in order to ensure proper representation by including participants from geographically diverse areas. The sample was stratified with proportional allocation regarding gender , age group , and public healthcare region. The stratification regarding geographical area was included to be able to explore any possible occurrences of systematic differences due to region. This was tested by one-way ANOVA, which did not indicate such differences. Within each stratum the participants were randomized according to the two methods of administration, telephone interview and postal questionnaire. The selected eligible sample consisted of 840 individuals who were invited to participate, 391 of whom were approached through telephone interview and 449 by a postal questionnaire.The SF-36 was developed by an American research group, led by John Ware . It was Based upon the eight scales, two summary scales have been constructed for physical and mental health respectively . The PhyThe SF-36 has been extensively validated in an American context ,22, and The HADS is a brief self-report screening scale, developed by Zigmond and Snaith (1983) , to inveThere are two ways of interpreting the HADS scores; either by comparing an individual's score to normative values obtained from a sample of the general population, or by using cut-off scores that indicate different levels of clinically relevant distress . Snaith The HADS has been used extensively, and is perceived as performing well when studying aspects of disease and quality of life in clinical as well as general populations . One stuThe HADS was originally developed for people aged between 16 and 65 . Only onThe study was approved by the regional ethical review board at the Faculty of Medicine, Uppsala University, Uppsala. The data was collected by Statistics Sweden between March and May 2005.After completing an organized training programme, five interviewers performed the telephone interviews. All potential participants received a letter containing information about the study. For those under 18, a separate information letter was addressed to the parents. Potential participants were contacted over the telephone by one of the interviewers within a week after the information letter was mailed. Provided that the respondent agreed to participate, and that parental consent was obtained for those under 18, a time was either booked for the interview, or in some cases the interview was conducted directly. The interviewer read the two questionnaires (the SF-36 version 1.0 and the HADS) aloud to the respondent, and recorded his or her responses. As a form of compensation, all participants received a cinema ticket by mail.Potential participants received a letter containing the two questionnaires (the SF-36 version 1.0 and the HADS) and information about the study, as well as a stamped and addressed envelope. In order to obtain parental consent, a separate information letter was addressed to the parents if the potential participant was under the age of 18. Those who did not return the questionnaires within two weeks were sent a reminder. Shortly after their participation, all participants received a cinema ticket by mail, as a form of compensation.All statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS) version 14.0 .The SF-36 was scored by coding raw scores for each question, and recalibrating, summing, and transforming them into a scale from 0 (worst possible HRQL) to 100 (best possible HRQL), following the standard SF-36 scoring algorithms . Two sumst and 3rd quartiles are presented, as scores were not normally distributed. Regarding the HADS, those percentages of the sample classified as being mild, moderate or severe cases, as indicated by Snaith and Zigmond's criteria [Sample characteristics are presented descriptively (frequencies and percentages). In order to provide normative data for the SF-36 and the HADS, score distributions are demonstrated. Apart from means and standard deviations, medians, and 1criteria , are alscriteria . In ordeSample demographic characteristics and the response rate are presented in Table Important features of score distributions and estimates of reliability are presented for the HADS in Table In both methods of administration, males and females differed from each other regarding the scores of the SF-36 and the HADS on a number of subscales, see Table No significant differences were detected between the group of older adolescents (16–19 years old) and the group of young adults (20–23 years old). However, the group of young adolescents (13–15 years old) differed significantly from the two other groups on a number of subscales, in both methods of administration, see Table As all the three factors age, gender, and method of administration were found to significantly affect the reports of HRQL, anxiety, and depression, normative values are in addition presented divided by the three variables simultaneously, see Table Normative data for the SF-36 and the HADS have been obtained from a large and stratified sample of the general population of adolescents and young adults in Sweden. It should form an important basis of comparison for future studies of these age groups, both of clinical groups and of the general population.When assessing HRQL in adolescents, the question is raised whether to use questionnaires specifically designed for children and adolescents or instruments like the SF-36 and the HADS that are mainly developed for adults. Both approaches are entailed with several advantages and disadvantages, some of which are broached by Eiser and Morse in an exhaustive systematic review . It can In line with findings from the overwhelming majority of research about HRQL, the males reported higher scores than the females ,15,17,30Although the systematic difference in subjective well-being between males and females is a common finding, very few explanations or interpretations have been presented as to why this is the case. One researcher who does focus on this matter is Helen Sweeting, who reviews findings on gender differences in health among children and adolescents . She conIn some respects, the group of young adolescents (13–15 years old) reported higher HRQL and less emotional distress than the older participants. It appears as if increasing age is also connected to a decrease in HRQL among adolescents and young adults. This too is in agreement with previous research . As otheA strong point of the present study is that the normative data is presented according to survey mode – telephone interview or postal questionnaire. It is evident that the choice of administration method has a decisive influence on the data that will be obtained. Apart from the statistical difference between the two modes of data collection, a central matter is whether this difference is sufficiently large to have any clinical importance. No minimal clinically important difference standards have been established for the SF-36. However, studies of the score profiles of various clinically defined patient groups have suggested that a 3–5 point change in scale scores may represent a clinically important difference -36. AlthIt is of interest that different groups seem to respond to the mode of administration in diverse ways and to varying degrees, which is also something that researchers should take into account when planning the design of future studies. Both gender and age were shown to have an impact on how people responded to the two methods of administration. Males and females alike tended to report better scores in the telephone interview compared to the postal questionnaire, but the difference was more marked among the females. Contrary to both adults in general and the two older age groups, the youngest age group did not evaluate their HRQL more positively when interviewed over the telephone than when filling in a postal questionnaire. This finding is surprising, and we feel that more research is needed to understand why the youngest respondents react differently to survey mode. One explanation could be that the young adolescents do not follow the rules of social desirability to the same extent, and consequently feel no need to adjust their responses according to expectations.There are some methodological limitations which should be mentioned. To minimize the risk of possible regional differences, the participants were stratified regarding three geographical areas. However, the regions chosen are vast and encompass small towns and big cities as well as rural areas. Differences due to these circumstances might exist but not come to light in this design. Additionally, there was a difference in response rate between males and females, resulting in more females than males responding to the mail-administered questionnaires. As females generally seem to report worse HRQL, this might have had some influence on the result.In conclusion, the study provides pertinent and valuable information about measuring HRQL in adolescents and young adults, a field which has been the subject of little research. In addition, the study presents current normative data for the SF-36 and the HADS for this age group. Furthermore, attention is being directed towards matters that should be investigated further, such as what factors underlie the gender difference which seems to appear in adolescence, and what makes young adolescents respond differently to survey mode used. Most of all, the results stress the importance of taking age, gender, and method of administration into consideration, both when planning studies and when comparing results from different groups, studies, or over time.The author(s) declare that they have no competing interests.AJ wrote the manuscript and conducted the analysis of the data. LW participated in data analysis and revised the manuscript critically. LvE conceived of the design of the study, participated in the analysis of the data and revised the manuscript critically.


It is difficult to systematically search for literature relevant to palliative care in general medical journals. A previously developed search filter for use on OVID Medline validated using a gold standard set of references identified through hand searching, achieved an unacceptably low sensitivity (45.4%). Retrieving relevant literature is integral to support evidence based practice, and understanding the nature of the incorrectly excluded citations  using the filter may lead to improvement in the filter's performance.The objectives were to describe the nature of subjects reflected in the false negative citations and to empirically improve the sensitivity of the search filter. A thematic analysis of MeSH terms by three independent reviewers was used to describe the subject coverage of the missed records. Using a frequency analysis of MeSH terms, those headings which could individually contribute at least 2.5% to sensitivity (occurring 19 or more times) were added to the search filter. All previously run searches were rerun at the same time as the revised filter, and results compared.Thematic analysis of MeSH terms identified thirteen themes reflected in the missing records, none of them intrinsically palliative. The addition of six MeSH terms to the existing search filter  led to an increase in sensitivity from 46.3% to 64.7%, offset by a decrease in precision from 72.6% to 21.9%.The filter's sensitivity was successfully increased using frequency analysis of MeSH terms, offset by a decrease in precision. A thematic analysis of MeSH terms for the false negative citations confirmed the absence of any intrinsically palliative theme or term, suggesting that future improvements to search filters for palliative care literature will first depend on better identifying how clinicians and researchers conceptualise palliative care. It is suggested that a constellation of parameters: stage of disease (advanced or active), prospect of cure (little or none), and treatment goals  may ultimately inform search strategies. This may be similarly true for chronic diseases, which share the inherent passage of time which marks them apart from acute, and therefore more readily identifiable, episodes of care. It is difficult to systematically search for literature relevant to palliative care. It is a diffuse subject, embracing topics from multiple other disciplines, and with relevant papers likely to be published in general medical journals as well as discipline specific journals. To facilitate improved identification of these papers, an earlier study formulated and evaluated palliative care search filters for use in the general medical literature, as part of a larger project, the Evidence Based (CareSearch) Project ,2. This Using a methodological approach often used to evaluate new diagnostic tests in medicine, and previously used to develop validated search filters , four geThis current paper reports a study investigating the nature of this subset of records. The objectives were to improve empirically the sensitivity of the Master Search and to describe the nature of subjects reflected in the incorrectly excluded citations.This research was undertaken May – November 2006 at the Repatriation General Hospital, Adelaide, South Australia. A set of incorrectly excluded citations was created by comparing records in the gold standard reference set (those identified in the previous study using a hand search) with records retrieved by the Master Search (the best performing MeSH and textword search). Items held in the Gold Set but not retrieved by the Master Search were regarded as false negatives, that is, they were incorrectly excluded when the Master Search was run. A set of 418 records were identified, and was called the Silver Set to distinguish it from the original hand search set of 773 records (the Gold Set). An Excel spreadsheet containing the citation details of the incorrectly excluded items was created.A frequency analysis of all MeSH terms in the Silver Set was undertaken. These were originally derived from four general medical journals; JAMA, The Lancet, BMJ and Annals of Internal Medicine, published from 1999 to 2001. The entire set was downloaded into a Word document, and all data except for MeSH terms were deleted. These terms were reformatted into a list, which was then exported into an Excel spreadsheet, and sorted into alphabetical order. Frequencies were tallied for all terms, including sub headings attached to MeSH terms, but ignoring whether or not terms were tagged as a major heading.th November 2006.A Revised Master Search was devised incorporating the most frequently occurring MeSH terms. It was calculated a priori that an increase of 2.5% sensitivity in the Gold Set n = 773) would equate to 19 additional records being retrieved from the Silver Set. This was a subjective estimate of the percentage increase that might represent a worthwhile improvement when offset against anticipated decline in precision. The Revised Master Search therefore combined the previous Master Search with the additional MeSH terms which demonstrated frequencies of higher than 19 (using the Boolean operator 'or'). Retrieved citations were then compared with those in the Gold Set, using a purposely written computer program called SSV , described elsewhere [73 would drug related therapies (RS) and palliative medications (JT) were grouped with therapeutics for symptoms (DC) using this process. A meeting was then held during which the spreadsheet was discussed, and consensus reached regarding a list of broad themes.As MeSH terms should reflect the major subject foci of an indexed article, the full list of all terms used was provided to RS , JT  and DC . Each separately, and independently, identified the major themes they thought were reflected by the range of these terms. One list (DC's) was tabled in a spreadsheet, and RS and JT then collocated their identified themes against this list according to similarity. For example, th November 2006 compared to 30th June 2005. , prognosis (29), quality of life (26), survival rate (26), treatment outcome (23), and attitude to health (21)  and a total of 10.27 MeSH terms per article (4293 occasions/418 references). When certain terms were disregarded , the most frequently occurring terms were When these six MeSH terms were added to the Master Search to create the Revised Master Search Table  and resuEach researcher identified slightly different individual themes in their individual analyses . Consensus was readily achieved in discussion, resulting in a final list of 13 broad themes, for example, drug therapies for symptoms, non-drug therapies for symptoms, disease modifying therapies, and pain and other symptoms Table .Incorrectly excluded citations from a previously validated palliative search filter were studied using frequency analysis of MeSH terms, resulting in the additional inclusion of headings which empirically improved the sensitivity of the original Master Search. Not unexpectedly, both specificity and precision decreased with this Revised Master Search.Notably, the sensitivity of the Revised Master Search was higher than that achieved by three relevant and published search strategies -7, modifThe overall large number of unique MeSH terms supports the conceptualization of information relevant to palliative care as diffuse, that is, spanning many subject areas . No cleaethics, pain and other symptoms, and drug therapies for symptoms are relevant to many other disciplines, not just palliative care.The thematic analysis of all MeSH terms included in the Silver Set (incorrect exclusions from the first study) was used to investigate this question, and yet did not provide any clear answers. None of the themes, or the individual MeSH terms which we reviewed to identify the themes, are intrinsically 'palliative'. Indeed, a similar analysis in any number of other specialties, such as rheumatology or internal medicine, might reveal a similar range of themes. For example, the themes of arthritis, rheumatoid; cardiovascular diseases; depression; dementia; and asthma. In isolation, none of these diseases are necessarily palliative. Numerous terms relating to cancer were also revealed, for example: adenocarcinoma; breast neoplasms; brain neoplasms; prostatic neoplasms; and neoplasms. Although many cancers are progressively life limiting, the prognosis for many cancers, particularly with early intervention, is good. Thus it cannot be presumed that these are inherently relevant.It is true that summarizing the Silver Set using themes might obscure MeSH terms which are more readily identifiable as palliative, however this was not the case. Using the 'diseases' theme as an example, some of the MeSH terms which led to the identification of this theme included: If the MeSH terms individually do not suggest immediate relevance to palliative care, then it is perhaps the underlying constellation of concepts and terms in individual articles which led to their original identification. For example, perhaps a cluster of MeSH terms and textwords, in unison, reflect something which a clinician recognizes as relevant to palliative care. This would not be surprising, as it would likely reflect the multifaceted nature of what constitutes an episode of palliative care. In developing such a definition for the Australian National Sub-acute and Non-acute Patient (AN-SNAP) Version 1 Casemix Classification, a cluster of parameters identified an episode as palliative, rather than simply diagnosis. These parameters included stage of disease (advanced or active), prospect of cure (little or none), and treatment goals , evidenced by assessment and management of a range of individual needs , and a grief and bereavement process for the individual and their carers/family .prognosis, survival rate and treatment outcome. Yet even for physician-patient relations, quality of life, and attitude to health, all reflect a notion of an inherent timeline.We also speculate that it is the changing nature of a disease over time which can identify it as potentially 'palliative'. All of the six additional MeSH terms incorporated in the Revised Master Search intrinsically reflect the passage of time. This is most identifiable with This study highlights the value of frequency analysis of MeSH terms, a third generation approach considered to be a more rigorous method . Whilst One limitation of this study relates to the online version OVID Medline not being static due to updating over time. Changes were made to the underlying records in between the original study and the current research (approximately 18 months). Whilst this was addressed by re-running all searches at the later date for comparison purposes, it is true that the actual MeSH indexing may be different to the original study from which the Silver Set was created. This means that the underlying frequencies of MeSH terms used to inform the revision of the search may be marginally inaccurate. We do not think the implications are great however, as our original study located 351 records which were in both the Gold Set and the Master Search; when this search was rerun the figure rose to 358 records. In other words, there were an additional seven relevant records retrieved. Given the publication period chosen for the original study was 1999 to 2001, it is sobering to realise that retrospective indexing has so recently been undertaken, that is, in 2006. Such delays in indexing may have implications when identifying the literature for systematic reviews, depending on the topic, and support the need for search strategies that are not solely contingent upon searching bibliographic databases.Generalisability in this study is difficult to assess. Because it builds on the previous study, it shares issues such as being based on a restricted subset of journals, described more fully elsewhere . No valiWhilst this study has described the themes represented by references incorrectly excluded in the use of a validated search strategy, it would be inappropriate to suggest these themes reflect how palliative care overall is conceptualized. A similar analysis of 'correctly included' references, that is, those which were readily identified as relevant to palliative care, would also be required. The most important next step may be an exploration of clusters of MeSH terms and concepts, which together reflect that an article is likely relevant to palliative care.The sensitivity of an existing search filter for identifying literature relevant to palliative care was successfully increased from 46.3% to 64.7% using frequency analysis of MeSH terms. This was notably offset by a decrease in precision from 72.6% to 21.9%. A thematic analysis of MeSH terms for incorrectly excluded references confirmed the absence of any single theme (or term) that was intrinsically palliative, suggesting that future improvements to search filters for literature relevant to palliative care literature will first depend on better identifying how clinicians and researchers conceptualise this discipline. On the basis of an existing definition for a palliative care episode of care, we suggest it may be a constellation of parameters: stage of disease (advanced or active), prospect of cure (little or none), and treatment goals  which may ultimately inform improved searches. This may be similarly true for chronic diseases, which share the inherent passage of time which marks them apart from acute, and therefore more readily identifiable, episodes of care.The author(s) declare that they have no competing interests.RS, JT and DC participated in the conception and design of the study. JT identified and extracted the records referred to as the Silver Set. RS undertook the frequency analysis of MeSH terms. All authors undertook the thematic analysis of MeSH terms. RS, JT and DC discussed the findings and the implications of same, and RS drafted the manuscript to reflect that discussion. All authors were involvedin the revision of paper and authorised the final version for submission.The pre-publication history for this paper can be accessed here:


Geographical objectives and probabilistic methods are difficult to reconcile in a unique health survey. Probabilistic methods focus on individuals to provide estimates of a variable's prevalence with a certain precision, while geographical approaches emphasise the selection of specific areas to study interactions between spatial characteristics and health outcomes. A sample selected from a small number of specific areas creates statistical challenges: the observations are not independent at the local level, and this results in poor statistical validity at the global level. Therefore, it is difficult to construct a sample that is appropriate for both geographical and probability methods.a priori determinants that can influence the spatial homogeneity of the health characteristics. This method yields a distribution of variables in the sample that closely resembles that in the overall population, something that cannot be guaranteed with randomly-selected clusters, especially if the number of selected clusters is small. In this way, we were able to survey specific areas while minimising design effects and maximising statistical precision.We used a two-stage selection procedure with a first non-random stage of selection of clusters. Instead of randomly selecting clusters, we deliberately chose a group of clusters, which as a whole would contain all the variation in health measures in the population. As there was no health information available before the survey, we selected We applied this strategy in a health survey carried out in Vientiane, Lao People's Democratic Republic. We selected well-known health determinants with unequal spatial distribution within the city: nationality and literacy. We deliberately selected a combination of clusters whose distribution of nationality and literacy is similar to the distribution in the general population.This paper describes the conceptual reasoning behind the construction of the survey sample and shows that it can be advantageous to choose clusters using reasoned hypotheses, based on both probability and geographical approaches, in contrast to a conventional, random cluster selection strategy. Geography is an independent scientific approach, while statistics simply constitutes a body of methods and tools that can be employed by scientists from various fields of research. Probabilistic statistics can be used to estimate a variable's prevalence in a given population with a certain precision. However, analysing survey data in this way can become complicated when the sample is selected using a geographical approach. The geographical approach often favours the study of specific areas, deliberately chosen to enable analysis of processes and interactions that are key to the understanding of particular health behaviours and spatial disparities. Cluster samples chosen from a small number of specific areas raise an important statistical challenge, in that the non-independence of observations within clusters has an impact on the statistical validity of the sample at the global level. Waldo Tobler showed in his first law of geography that "everything is related to everything else, but near things are more related than far things" . TherefoThe geographical approach calls for selecting specific places from where health information about large segments of the population can be acquired, in order to study interactions between people living in the same place. Selection of specific areas allows precise descriptions of the environment  and its relationship with health, which would be very difficult to assess for a whole city. It is interesting to select some relevant territories where it is possible to study health spatial disparities, to explore interactions between people and places and to gain a better understanding of spatial organisation in a given society. Additionally, to analyse health spatial disparities, geography researchers often distinguish between the effects of "context"  and "composition"  in contextual and multilevelanalyses; these analyses therefore require datasets including individuals nested within areas or neighbourhoods . In concAt the same time, it would be useful if the study also produced an estimate of prevalence for each important health variable, and identified health-seeking behaviours and individual risk factors. Such findings help inform public health policy decisions. Indeed, as the Asian Development Bank noted regarding Lao PDR, "there is an urgent need for a nationwide survey of household sanitation in urban areas. This can be a sample survey as long as the sample size is representative" . TherefoStratification can improve the representativeness of a sample by reducing sampling errors, and can make variance estimates more precise . If survThe most commonly used spatial sampling method is cluster sampling: the studied area is divided into units, and a selection is then randomly chosen. Within each unit, individuals are ideally chosen by simple random sampling. Cluster sampling economises on time, budgets and energy; it is often done primarily for these practical reasons, as in the Expanded Programme on Immunisation (EPI) , becauseThe statistical precision of cluster sampling can be improved by increasing the number of clusters. At the extreme, when all of the clusters are sampled, one effectively has a stratified sample, typically associated with increased levels of precision. At the other extreme, if only one cluster is selected, results would be specific to that cluster and not necessarily generalizable to the global population. To improve representativeness of the overall sample, it is best to select many areas, even if this means sampling fewer individuals within each area . It is o1. The number of clusters must be sufficiently large that statistical precision at the population level is adequate, and spatial comparisons remain possible, and2. The number of clusters must be sufficiently small for the survey to remain logistically feasible, and for geographical analyses to be performed properly at the local scale.Random cluster selection does not necessarily mean that the sample of clusters is representative of the whole population, especially when the number of clusters sampled is small; in fact, the design effect is highly dependent on this number. The variance obtained by cluster sampling can be reduced by selecting areas that are as internally heterogeneous (i.e. have a full range of variability within them) as possible and as externally homogeneous (i.e. are as similar to one another) as possible. The ideal situation, in terms of statistical precision, would be that each area was a microcosm of the entire population and, therefore, was perfectly representative, in terms of variability, of the overall population . HoweverTo reconcile probabilistic methods and geographical objectives, we propose purposeful, rather than random, selection of a group of clusters that together could contain all the variability of the overall population.n clusters, such that respondents are representative of population heterogeneity . Since no health information is available before the survey, a priori variables that can influence the spatial homogeneity of health characteristics in the studied area have to be determined. The notion of resemblance is subjective, but it aims to ensure that any two given populations resemble each other in terms of the phenomenon being researched. The choice of n clusters is thus based on reasoned hypotheses and on the specific research objectives. Cluster selection is therefore conceptually derived from a set of definite hypotheses, which is necessarily different from the hypotheses another group of researchers might have. Among every available variable, we select well-known health determinants  and keep some variables  with unequal spatial distribution within the studied area. It is possible to check the survey results after the research has been carried out for a posteriori relevance of the given variables as health determinants.To improve the reliability of our sample, consisting of a small number of clusters, we have to choose the best combination of n clusters whose composition is most similar to the composition of the overall studied area, it is first necessary to list all the possible combinations of n clusters (without repetition) among N clusters existing in the studied area. Usually, we obtain a large number of combinations:To select the combination of Cb is the number of possible combinations of n clusters without repetition; N is the total number of clusters existing in the studied area and n is the number of clusters we want to select.Where n clusters, the mean squared difference between the proportion of v1  in each of the n clusters  and the mean proportion of v1 calculated at the studied area level (Pv1area).It is then necessary to calculate, for each combination of 1 calculated at the studied area level. Cluster combinations are retained where the mean difference corresponds with the variance calculated for the studied area. The same steps are followed with every selected variable (v2...vn). Among the large number of possible combinations of n clusters, few combinations are obtained, whose variability of different selected variables is very similar to the variability calculated at the studied area level. This procedure enables clusters to be selected that have a composition of a priori health determinants that is similar to the composition of the a priori health determinant in the overall studied area. With this procedure, we hope to reduce design effects and gain statistical precision while surveying only a few clusters.This mean squared difference is compared with the variance of vWe applied this form of clustered sampling to a health survey conducted in Vientiane, Lao PDR.ban) is the smallest administrative, religious and political unit in both rural and urban areas. The spatial division into villages reflects political, administrative and social reality and, as census data are available at the village level, we decided to keep the village as the reference unit for the survey: a cluster thus corresponds to a village. In 2005, an average of approximately 1870 people lived in a Vientiane City village (interquartile range: 1080 – 2311). It is likely that the increased urbanisation of the capital has led to wide disparities in health, but as little health information exists, there is no way to know what kind of health problems the population encounters and how people seek healthcare. To provide health data and to analyse health spatial disparities in Vientiane, the French Research Institute for Development (Institut de Recherche pour le Développement – IRD) carried out a health survey within the city in collaboration with the Lao Ministry of Health, the National Institute of Public Health, the Faculty of Medical Sciences, the Francophone Institute of Tropical Medicine  and the Microbiology Laboratory in Mahosot Hospital. Ethical approval for this survey was obtained from the Lao National Ethics Committee for Health Research in Lao PDR.The main objective of the research programme, entitled "Urbanization, Governance and Spatial Disparities of Health in Vientiane", is to describe and analyse the organisation of urban areas  as sources of intra-urban health inequalities. The urbanised area of Vientiane is spread over 148 villages ('ban' in Lao) comprising approximately 277,000 inhabitants in 2005 . In Lao Two age groups were selected: children (aged from six months to less than six years) and adults (aged 35 years and above). Data were collected in February and March 2006 through household and individual questionnaires. Household questionnaires collected data on house location and description, living conditions, incomes, community bonds and demographic data on every member of the household. Individual questionnaires collected demographic data and socio-economic information, urban lifestyle variables, behavioural risk factors, health status data, and healthcare-seeking behaviours. Health status was measured through medical examination and investigations . Healthcare-seeking behaviour was examined through questions about type and gravity of health problem, local health structure, price, quality, and satisfaction with health care services.With these data, we aimed to: (i) compare levels of morbidity in different urban areas; (ii) identify appropriate urban scales for recognising health disparities; (iii) detect hotspots of morbidity using exploratory spatial data analysis; and (iv) measure the impacts of both social and urban contexts using multilevel analyses.As the main objective of this programme was to study the relationship between urbanisation and health, the first stage of this health survey required us to set the spatial limits of the urbanised area of Vientiane and to stratify this defined area . To set Budgetary limitations affected the overall sampling size: 2000 adults and 2000 children for the whole city (or 666 adults and 666 children in each urban stratum). This allowed for a 95% CI of +/- 2.3% around a prevalence of 10% at the stratum scale, and +/-1.3% around a prevalence of 10% at the city scale. In this calculation, we have not considered the design effect. The value of the design effect (which differs between variables within the same survey) is difficult to estimate during survey preparation, and is very dependent on the selection of clusters. We planned to survey the same number of individuals in every village so that comparison could be done with the same precision. According to the size of the village population, we fixed a sample size of 27 villages (nine per urban stratum), with 74 adults and 74 children to be sampled in each village. This corresponds to a mean sampling rate of 1/5.6 for adults and 1/2.4 for children, based on the list of households created in December 2005 in every one of the 27 selected villages.For logistical convenience, we decided to re-group these 27 villages into nine groups of three adjacent villages, such that only one medical centre was needed for every three adjacent villages. Using a contiguity matrix, we listed in each stratum all the possible groups of three adjacent villages and produced all the combinations of three groups of three adjacent villages without repetition. We obtained a very large number of combinations table , from whAmong the combinations of three groups of three adjacent villages, we pre-selected combinations that were representative of urban characteristics. Despite already having stratified on degree of urbanisation, the small number of studied villages (nine) in each stratum still did not guarantee a good representation of urban characteristics within the stratum itself. To solve this problem, we used our hierarchical classification of urban characteristics to distinguish further sub-strata of urbanisation within each urban stratum, and defined three substrata in the central zone, four in the first urbanised belt and five in the second urbanised belt Figure . For eacAmong every available variable in the 1995 census, we selected two well-known health determinants with unequal spatial distribution within the city proper: nationality  and the level of education . The spatial heterogeneity of these two variables in Vientiane could influence spatial health distribution Figures  and 4. AAs described earlier, we calculated, for every combination of three groups of three adjacent villages, the mean squared difference of the proportion of those with Lao nationality and compared it with the variance of the proportion of those with Lao nationality calculated at the stratum level. We followed the same steps with the proportion of literacy. After this two-step procedure, we obtained a few combinations in each stratum whose variability of nationality and education was very similar to the variability calculated at the stratum level. We chose from among these the combination villages for which there were no logistical problems . This procedure provided three combinations of nine villages Figure . Table 2To obtain a sample in every selected village as reliably as possible  respondents needed to be selected randomly. With the help of village authorities, we created a sampling frame in each village and then selected households to survey at random. Within each selected household, a maximum of one adult and one child were allowed to participate in the survey. The probability of household selection was proportional to the number of eligible people in the household.In developing this sampling frame, the main difficulty we encountered was the lack of data available on the population. We needed to ascertain accurate information about some health determinants and about their spatial repartition. For the Vientiane survey, only urban data from 1999 with aerial photographs, demographic data from the 1995 census, and the number of inhabitants per village from 2005 census were available. Precise demographic data from the 2005 census  were not yet available during the preparation for this survey.For the health survey in Vientiane, we adopted a two-stage selection procedure with a first non-random stage of selection of clusters: we chose clusters that would be representative of the urban and health variability of the global population. Conventional random cluster sampling is certainly statistically appropriate when the number of clusters is large. However, when only a small number of clusters are sampled in order to correspond to geographic objectives and/or to logistical needs, it becomes statistically more appropriate to choose clusters instead of randomly select them. Where this method is used, the choice of clusters should be based on reasoned hypotheses and on the specific research objectives. A modified clustered design with a first non-random stage of cluster selection can provide appropriate information both to study health spatial interactions and to estimate other health variables, such as prevalence, at the city level.The author(s) declare that they have no competing interests.JV performed the sample design, organized the Vientiane health survey and drafted the manuscript; MS and FF took part in the reasoning associated with the construction of the survey sample and corrected the manuscript. MS contributed also to the conception of the sample design; AB, VM made comments about geographical approach and organized Vientiane health survey; KP and GS participated to survey organization. All authors read and approved the final manuscript.


The consequence of the low rate of penetrating injuries in Europe and the increase in non-operative management of blunt trauma is a decrease in surgeons' confidence in managing traumatic injuries has led to the need for new didactic tools. The aim of this retrospective study was to present the Corso di Chirurgia del Politrauma (Trauma Surgery Course), developed as a model for teaching operative trauma techniques, and assess its efficacy.the two-day course consisted of theoretical lectures and practical experience on large-sized swine. Data of the first 126 participants were collected and analyzed.All of the 126 general surgeons who had participated in the course judged it to be an efficient model to improve knowledge about the surgical treatment of trauma.A two-day course, focusing on trauma surgery, with lectures and life-like operation situations, represents a model for simulated training and can be useful to improve surgeons' confidence in managing trauma patients. Cooperation between organizers of similar initiatives would be beneficial and could lead to standardizing and improving such courses. The treatment of the thoraco-abdominal trauma has always represented a surgical challenge, owing to the peculiarity of these injuries. The need for specific training for surgeons involved in the care of these patients is justified by the difficulties in obtaining an exhaustive pre-operative assessment, the need for prompt decision-making, and the often limited available resources.Furthermore, the number of surgically treated trauma patients has markedly decreased in recent years, owing to many factors, such as the low rate of penetrating trauma, the improved safety system of vehicles, innovations in diagnostic tools, and the discovery of alternative treatments -4. Thus,in vivo animal models, generally large-sized swine, which simulate human thorax and abdomen quite well, enables extremely realistic situations to be recreated, even to the point of putting the participants under stress [A variety of didactic methods, based on "simulated training", have been suggested ,8 and cor stress ,9,10.In Italy the general surgeon is trained by six-year residency in General Surgery or in General and Emergency Surgery. However, there are no specific residency or university courses for Trauma Surgery. Managing trauma differs greatly from region to region; in most regions there is a lack of reference centers for thoracic and abdominal traumas, which are treated by the general surgeon of the nearest hospital, whereas specific traumas, such as neurosurgical, orthopedic and burns, are treated by specialized surgeons.Instead, in our region (Emilia-Romagna) there are three reference trauma center . These centers are equipped with all the necessary resources to treat all kinds of trauma.Since November 2002, a multi-trauma surgery-training course has been running in Bologna, Italy, which is mainly aimed at general surgeons, who, owing to their work, more frequently run into trauma injuries and residents who currently have less chance to gain experience in trauma surgery.The aim of this study was to present this course and discuss its purposes and educational effectiveness compared with similar courses. We also wanted to assess whether our model could be used as a qualified updating course. We present herein the results obtained in the first seven editions of the course.Gruppo Aperto per lo Studio del Trauma – GAST) belonging to the Clinical Emergency Surgery and Emergency Unit at La Sapienza University in Rome, Italy. The Trauma Surgery Course was conceived to share the experience of these two groups with other surgeons involved in trauma patient management. The course is mainly aimed at thoracic and abdominal trauma, as this usually involves the general surgeon, while specific topics, such as neurosurgical or orthopedic aspects are addressed in lessons on "Multispecialized approach in E.R." and "Complex pelvic truma".Our project is based on the experience acquired in thoracic and abdominal injuries at Maggiore Hospital of Bologna, Italy, over the last 16 years. This hospital has been a reference centre for trauma management for several years, with over 400 cases of major (ISS>25) traumas per year. Cooperation has been set up between our multidisciplinary team of Emergency Surgery and Trauma and the Open Group for the Study of Trauma ; 12 out of 14 physicians are ATLS qualified, and 8 of them are ATLS instructors.The course is restricted to 18 participants, selected on a first come first served basis, owing to the difficulty to equip the veterinary operating rooms and enable each participant to practice the surgical techniques. The course lasts two days. Day one focuses on theoretical aspects, by analyzing the main topics of diagnosis and treatment   and consists of surgical exercise on large-sized swine. All the participants are invited to perform the common surgical procedures Table  used in The importance of the effectiveness and speed of intervention is frequently stressed. The animals are alive, intubated and monitored under the care of a veterinary anesthetist for the duration of the intervention. To better simulate a life-like situation, each table of the operating theatre is equipped and served by a qualified surgery nurse. For each animal there are 3 participants, distributed according to their capability and experience, and 2 tutors (1 for the abdomen and 1 for the thorax). The animals are treated in accordance with the Italian law on the use of laboratory animals.The comprehensive evaluation of the degree of learning takes into account technical skills, the ability to understand the clinical aspects, identify priorities, and repair the induced lesions in a life-like situation. The participants are evaluated by the tutors of the practical part of the course and rated: insufficient, sufficient, good, and excellent. Three different scores are attributed for abdominal surgical techniques, thoracic surgical techniques, and emergency surgery techniques, such as damage control and emergency thoracotomy.Twenty CME credits  are awarded by the National Committee for Continuous Training. All the participants receive a form to fill in to evaluate the training course in terms of relevance of the topics, quality of teaching, and effectiveness in providing a continuous education.The course is held twice a year and is standardized and fully reproducible.At the end of course each participant is issued with a certificate.In the first 7 courses held from 2002 to 2005, 126 participants attended from 19 regions, uniformly distributed among northern, central and southern Italy.The mean age of participants was 43.9 years (range 30–60); ten were women . 124 were general surgeons or worked for humanitarian organizations and 2 were fifth year residents. The mean work experience, after residency, was 16 years (range 3 months – 33 years). Nine (7.1%) participants were heads of surgery units.All the participants attended the theoretical lessons and had the opportunity to practice the programmed surgical techniques starting from the abdomen and ending with the thorax and heart.Since the participants were grouped based on their capability and experience, during the practical stage they were evaluated accordingly.None of the participants received an "insufficient" score. , with the majority of them rating good or excellent in all three fields .54 (42.8%) participants defined the course as "highly relevant", 70 (55.5%) "relevant", and 2 (1.5%) "quite relevant". None of the participants defined the course as "slightly" or "not relevant".The quality of the teaching on the course was considered by the participants as "excellent", "good", and "satisfactory" in 81 , 44 , and 1  cases, respectively. In no instance the quality of teaching was considered as "mediocre" or "insufficient".Finally, with respect to the evaluation of the efficacy of the course in providing a continuous education, the answers of participants were "highly efficacious", "efficacious", and "moderately efficacious" in 77 , 36 , and 13  cases, respectively, whereas none of the participants defined it "partially efficacious" or "totally inefficacious".The need to train surgeons to apply emergency surgery techniques not commonly applied, and to use new instrumentation has led to the spread of training programs based on life-like simulations, using instrumental or animal models -14. NormThe problem concerning specific training for the trauma surgeon has been dealt with in the past years by organizing courses with surgical simulation. The International Association for Trauma Surgery and Intensive Care organized a two-day course on the Definitive Surgical Trauma Care, including both theoretical and practical training on cadavers and live animals . A one-dThough we started from a different background, our proposal is very similar. The structure of our course is original but comparable to the few courses held in the USA and in other non-European countries. The "main topics" and the life-like situations for the evaluation of practical skills are essentially the same. However, the peculiarity of our course is that we pay more attention to the multidisciplinary approach as well as to diagnostic and resuscitation problems. Another peculiarity of our course is the presentation of some lectures by experienced nurses, in the idea of providing supportive arguments to the concept that the traumatized patient is a very complex one, and that only a multidisciplinary approach can produce the best outcome.We obtained very encouraging results from the first courses due to the high degree of attention paid during teaching sessions and the participation in the discussion of clinical cases. Therefore, although the parameters were not easily quantifiable, all the participants demonstrated with varying degrees of skill that they could successfully manage "unfamiliar surgical situations". Moreover, the participants judged the course to be very useful for their own training: more precisely, 98.3% rated the course favorably with regards to the need for personal updating; 99.1% for the quality of the teaching and 89,6% for the efficacy of the course for personal training. To further improve the theoretical aspects of the course, we currently mail some of the lectures before the course begins, with the aim of giving the participants pre-course preparation.On this basis, we can reasonably assume that the course was successful, due both to the peculiarity of the topic and the involvement in the practical section of the course. The participants coming from all the Italian regions indicated that the need for CME for surgeons involved in the management of such injuries was felt in many centers.Of note, all but two of the participants had previous vast working experience. This can be explained by the fact that participation fee (the fee for 2005 was € 1200) is quite high and more likely to be afforded by senior surgeons. However this cost only covers the overheads of the course. This highlights the difficulties in participation of post-graduate residents that are still in training, unlike the American course that attracts not only attending surgeons but also fellows and residents . One wayIdeally, a course should provide a theoretical education and a practical training of participants, by obtaining their direct involvement, and thus responding to their needs and expectations. With regards to the continuous education program, a future improvement of the course might be achieved by organizing workshops on particular clinical cases or on particular implications in the treatment of polytrauma. We are currently preparing a questionnaire to distribute to ex-participants in order to verify the course's impact on their day-to-day work.The problem of training trauma surgeons, i.e. the lack of experience in treating traumas in operating room, is common to all countries  and the Since we are aware that most participants of our courses work in hospitals where the management of trauma patients is not common, we have introduced sections focusing on diagnosis, the emergency approach, and nursing management in the operating room and in the ward. This represents the peculiarity of our course compared to others.Finally, considering that most training programs have a common basis and teaching method, we think that cooperation among the teaching staffs that organize similar courses would be useful to ensure a uniform standard course with a single tested method with regards to evaluation of the participants, choice and assessment of the teaching staff, and planning of updating. This could lead to obtaining official approval as already occurs for the ATLS and, therefore, provide all participants with a similar background.In an age of advanced technology in distance learning with telematic and computer methods, we believe that a course on the management of trauma, designed to create extremely realistic conditions of stress in the operating room as in life-like situations is very useful to train the trauma surgeon.Besides the efficacy of the course, many other aspects should be discussed in the training institutions. For instance, if these courses are organized especially for surgeons who sporadically run into the traumatic diseases, should they become a mandatory part of training the general surgeon? If the main goal is to enable all surgeons to deal with traumas in the best possible way, how can we motivate students-in-training, who can hardly bear the expenses? On the basis of the results obtained previously in our courses and those of similar education programs, we can conclude that a theoretical and practical course, such as the "Trauma Surgery Course", is a good updating tool on trauma pathology for surgeons who work in Hospital Emergency Surgery Units or those belonging to Humanitarian Organizations, who are used to dealing with this pathology in foreign countries. Skills in trauma surgery should be an integral part of the surgeon's training and it would be important to gain the support of Scientific Societies  to carry out these courses. Integration with other courses would lead to a wider diffusion and recognition of the teaching method.


By Ingrid EckermanHyderabad, India:Universities Press, 2005. 283 pp. ISBN: 81-7371-515-7. Rs250The Bhopal Saga is an attempt to bring order from the chaos of events before, during, and after the methyl isocyanate (MIC) release. Not a scientific analysis, the book summarizes events leading up to the accident of December 1984 and the relief work in the ensuing two decades.After 20 years, victims, health care workers, and governments are still trying to comprehend what has been called the world’s worst industrial accident. Eckerman’s primary strength is her on-scene experience as a member of the International Medical Commission on Bhopal. She describes comprehensively the long-term health effects documented in the exposed population and suggests what might be done to improve health care for the victims. The paucity of data on certain end points, notably women’s reproductive health, childhood outcome, and cancer, is stressed. Also included is a summary of the positive and negative effects of various interim relief efforts on the population. Eckerman includes societal, economic, environmental, and political aspects that she considers imperative for integrated long-term health care.The range of acute and chronic health effects in the exposed population is placed in terms of the toxicity of the probable major components of the gas cloud. Unfortunately, Eckerman relied on secondary sources for this information, although the database for most of the individual chemicals is robust and contains controlled experiments in both humans and animals. The primary literature would have informed her that beyond contact irritation, toxicity of the isocyanates varies widely. For example, MIC is not a sensitizer and causes systemic toxicity, whereas other isocyanates are potent sensitizers and local irritants only.The Bhopal Saga, but this is almost a distraction. The known safety violations at the plant, the lack of education and training of workers, and the documented incidents of noncompliance before the leak speak for themselves; Eckerman even refers to the accident as a “massacre” or the “killings” in several places. The belief that Union Carbide is withholding data, especially the composition of the gas cloud, is speculation on her part. Current efforts by researchers in the United States to recreate the chemical reaction may soon answer the question of component gases. Although the issue is still debated in the medical community, Eckerman firmly believes that sodium thiosulfate should have been widely used as an antidote for the exposed victims: Eckerman concludes that sodium thiosulfate must have been necessary, not because of patient presentation, but because Union Carbide withdrew the initial recommendation for use of the cyanide antidote. Although it is probable that hydrogen cyanide was generated in the chemical reaction and was present in the gas cloud, cyanide has not been shown to be a breakdown product of MIC in human or animal systems. It is impossible to judge whether Union Carbide was basing its treatment recommendation on toxicity data or for some other reason.Nevertheless, the acute symptoms, delayed pulmonary effects, and chronic health problems are otherwise well correlated in the context of the known toxicities of the chemicals discussed. Both Union Carbide Corporation and the state and national Indian governments may deserve the constant accusations aimed at them in A list of other accidents at Union Carbide plants worldwide contains a mistake . Large quantities of mercury were used in the 1950s and 1960s at a U.S. Department of Energy facility that was managed at the time by Union Carbide’s Nuclear Division. Eckerman incorrectly states that half of the workers involved were killed, when in fact no adverse health effects have been found. In addition, effects of released mercury on the environment and surrounding communities have been studied extensively.Eckerman’s biases against industry and government can be forgiven when compensation was delayed for years, a reliable health care infrastructure is still not in place, environmental laws are not enforced, and worker safety appears compromised by lapses in oversight. Unfortunately, Eckerman offers no new solutions to the human rights issues specific to the Bhopal tragedy or to the world population in general.


The health of a nation could be said to depend upon the public health expertise of its scientists. In the United States and other developed areas of the world, it can be fairly simple to gain access to a variety of useful public health resources. But populations living in less-developed areas of the world often lack such knowledge and public health access. In 1987, two young scientists, William Au of the University of Texas Medical Branch (UTMB) and Wagida Anwar of Ain Shams University in Cairo, Egypt, decided to seek ways to raise the level of access to information and technical expertise regarding environmental health disparities in less-developed regions.With a main goal of encouraging collaborations for growth of scientific knowledge and expertise as well as clinical applications in underserved areas, they focused on organizing an international conference highlighting the latest research and information on environmental mutagens. The fruit of that labor, the International Conference on Environmental Mutagens in Human Populations (ICEMHP) series, has become a boon to the scientific community in developing nations. The next conference, sponsored in part by the NIEHS, is scheduled for May 2007 in Antalya, Turkey.EHP Supplements.NIEHS scientist Mike Waters, chairman of the ICEMHP International Advisory Board, says the institute has been a key participant in the conference series since its inception, noting that institute scientists have helped with organizing activities, and that NIEHS leaders have contributed personal and financial support. He also points out that the proceedings of the first two conferences were published in the October 1993 and May 1996 issues of According to Waters, the mission of the NIEHS lends itself to sponsorship of the ICEMHP series. “[The NIEHS] fosters national as well as international efforts to reduce the burden of environmentally associated disease,” he explains. “This series of conferences certainly has the same objective. It represents an effective means of communicating and extending the NIEHS mission and its research findings to the developing world.”Other past and current sponsors for the conference series include the U.S. CDC, Novartis Pharmaceutical Company, the U.S. Environmental Mutagen Society, the European Environmental Mutagen Society, the International Association of Environmental Mutagen Societies, the Turkish Society of Toxicology, Research Corporation, and the UTMB Department of Preventive Medicine and Community Health and Sealy Center for Environmental Health and Medicine.In recalling the impetus for initiating the first conference, Au reflects, “If you like your work, you think about what else you can do to make a difference, so we were looking for what we could do to have an impact. We recognized that major conferences were held in developed countries, and we thought: why not replicate this in other regions with a need for environmental health outreach?”With encouragement and support from their mentor, the late Frits Sobels of the University of Leiden, the Netherlands, the two young scientists saw the successful staging of the first ICEMHP in Anwar’s home-town of Cairo in January 1992. The Cairo conference was a noted success, with more than 200 attendees participating in symposia, oral presentations, poster sessions, and workshops. Following this conference, the Pan African Environmental Mutagen Society was formed, and Anwar was later named Egypt’s assistant minister of health.The accomplishments of this first meeting paved the way for the development of more ICEMHP conferences. Subsequent meetings have been conducted in Prague, Czech Republic (1995), Bangkok and Khao Yai, Thailand (1998), and Florianopolis, Brazil (2003), with each stimulating public health programs and collaborations in the host regions. Au, who has remained the driving force behind the conferences, collaborates with scientists native to each region when organizing the proceedings, and gives priority to locations where the field of environmental mutagenesis is still in the developmental stages. He says one of the main goals in choosing each location is to make the opportunity for the exchange of scientific information available to more people, particularly those such as students in developing areas of the world, who might not have the means to fly to cities across the globe where major conferences are usually held.Students, researchers, practicing clinicians, and each host country’s Ministry of Health are among the regular invitees to each ICEMHP. Students in particular are actively recruited; they are offered reduced registration fees, and are provided with copies of ICEMHP monographs they might not otherwise be able to afford––monographs containing valuable environmental health information they can consult as they develop strategies for positive impacts on health in their home regions.Radim Šrám, director of the Laboratory of Genetic Ecotoxicology at the Institute of Experimental Medicine in Prague, Czech Republic and co-organizer of the 1995 ICEMHP, sees the meetings as ideal platforms for the exchange of environmental health information to effect change in each participant’s home region. “Organizers try to bring to these meetings young scientists from developing countries, to stimulate their interest in the topics to be used in their countries. . . . These conferences become a friendly forum to understand the level of science in different regions as well as the differences among the exposure to carcinogens in different countries.” This information, he says, “may be later used for regulatory changes.” He also notes that conference activities always highlight the latest environmental mutagen research, including information on new methods and biomarkers for human studies, and how they should be processed and interpreted.Although organizers encounter a variety of issues unique to less-developed areas of the world during the planning years between each conference, they are usually able to work around these challenges. The conferences have had a steady increase in the rate of attendance over time, even though they have taken place during politically, socially, and economically challenging times. For example, the 2003 conference in Brazil had a record attendance of more than 600 individuals despite occurring during a time of turmoil in the Latin American financial market and at the height of worldwide concern about sudden acute respiratory syndrome and the risks of international travel.The conference budget also presents its own challenge. Unlike most established conferences, which are sponsored by professional organizations and societies, each ICEMHP depends wholly upon its organizers in seeking financial support. Invited speakers help defray some of the costs by paying their own travel expenses. Organizers have also received funding from outside sponsors such as individual environmental health experts and entities who see the intrinsic value in supporting the meetings.With four successful conferences behind him and the May 2007 conference coming up soon, Au is looking ahead to the continued fostering of sustainable programs and initiatives on the local level in developing countries. Locating the conferences in less-developed regions remains the cornerstone: ensuring that young scientists in developing regions have access to current thinking not only helps them improve their own knowledge and technical skills, but also fosters a new generation of environmental health policy makers, says Au.Furthermore, each meeting to date has helped forge collaborative efforts that have stimulated the development of local environmental mutagen societies and projects dedicated to improving local environmental health over the long term. Au says that connecting with environmental health decision makers in underserved areas to determine and address important regional issues will continue to help shape the ICEMHP series.


Being an important part of China's Urban Health Care Reform System, Community Health Centers (CHCs) have been established throughout the entire country and are presently undergoing substantial reconstruction. However, the services being delivered by the CHCs are far from reaching their performance targets. In order to assess the role of the CHCs, we examined their performance in six cities located in regions of South-East China. The purpose of this investigation was to identify the utilization and the efficiency of community health resources that are able to provide basic medical and public health services.The study was approved by Peking University Health Science Center Institutional Reviewing Board (NO: IRB00001052-T1). Data were collected from all the local health bureaux and processed using SPSS software. Methods of analysis mainly included: descriptive analysis, paired T-test and one-way ANOVA.The six main functions of the CHCs were not fully exploited and the surveys that were collected on their efficiency and utilization of resources indicate that they have a low level of performance and lack the trust of local communities. Furthermore, the CHCs seriously lack funding support and operate under difficult circumstances, and residents have less positive attitudes towards them.The community health service must be adjusted according to the requirements of urban medical and health reform, taking into account communities' health needs. More research is required on the living standards and health needs of residents living within the CHC's range, taking into consideration the users' needs in expanding the newly implemented service, and at the same time revising the old service system so as to make the development of CHCs realistic and capable of providing a better service to patients. Several suggestions are put forward for an attainable scheme for developing a community health service. Since they are considered an important part of the Chinese Urban Health Reform System, Community Health Centers (CHCs) have been established throughout the entire nation; they are currently undergoing substantial re-construction. Until 2002, 31 provinces including the autonomous regions and central government-ruled cities such as Beijing, Shanghai, ChongQing and Tianjin had a total of around 2406 CHCs and 9700 service stations. However, these CHCs are facing many problems in delivering their services, attributable to the different speeds of development among centers, lack of resources, and imbalance in the sizes of CHCs, so it is difficult for them to meet citizens' needs. Nevertheless, the CHCs are considered the main primary institutions for offering basic medical and public health services. They are regarded as the basic networks for medical treatment and public health surveillance. Therefore, redistributing health resources towards CHCs can ensure social health equality [st century, traditional methods could no longer cope with the tasks of the new CHCs or patients' health service demands such as care, emergency treatment and rehabilitation. Hence, there is an urgent need to develop the CHC services in order to meet the residents' demands. The main question is how to develop these centers and expand them, and at the same time be able to attract patients to use them. Another important question is how to build a trusting, stable and harmonious doctor-patient relationship. These are all important variables in the advancement of the Chinese health reform system.Traditional health methods such as Traditional Chinese Medicine (TCM) concentrate more on cure than prevention and/or care. By the beginning of the 21(1) Disease prevention and control: in disaster situations, the main task of the CHCs is to implement epidemic prevention measures effectively, while in more normal times it is to promote prevention among the residents. By following the sector's instructions on epidemic prevention, the CHC has to report carefully on the coverage of expanded planned immunizations (EPI) and the delivery of routine immunizations to children within their communities, such as carrying out community vaccine immunizations, investigating epidemics and contagious diseases, and other preventive procedures.(2) Health care services: these include health care surveys of family members, children, women, the elderly and the disabled.(3) Health education: by promoting geriatric and women's health education, and extending such education to students in schools around the country. In supporting the latter idea, the notion of a health-promoting school is relatively new. "The health promoting school aims at achieving healthy lifestyles for the total school population by developing supportive environments conducive to the promotion of health. It offers opportunities for, and requires commitments to, the provision of a safe and health-enhancing social and physical environment" . Also, health education is essential in providing residents, those located around the CHC, with general medical and disease prevention information and treatment consultations, so that residents' concepts of care and health investment are promoted(4) Family planning: the task here is to implement a nationwide family planning policy. This is performed by education and counseling about family planning.(5) Medical treatment service: the main work is to consult, diagnose and treat residents/dwellers for common, frequently-occurring and chronic diseases.(6) Community rehabilitation: this involves setting up family sick-beds, providing rehabilitation treatment and providing technical instructions for those who are considered disabled out-patients or those suffering from chronic diseases. However, owing to the scarcity of rehabilitation equipment and facilities, the community rehabilitation business is being dominated totally by TCM: acupuncture, moxibustion and massage. Thus, patients' needs can hardly be met.After 1949, the 'socialist medical cooperation centers (SMCCs)' were established in urban and rural areas, and the health care personnel who served in these centers or paid house visits were known as 'bare-foot doctors'. Notwithstanding the ability of these centers to cover and deliver medical care to large areas, the bare-foot doctors' technical skills became out of date. However, with the country's economic development, the government started to lose control over the SMCCs because of decreased state funding, and the centers were forced to become individually owned or abandoned, which led to the disappearance of the bare-foot doctors. Between the gradual disappearance of the SMCCs and bare-foot doctors and the establishment of the CHC system, there was a transitional period of two decades (1978–1998) during which the rural areas suffered a severe lack of medical facilities; there were no private clinics. At the beginning of 1998, the government started to establish the CHC system, and in some locations the erstwhile SMCCs became clinics owned by individuals. Later, the central government started to fund these private clinics and demanded that they put their facilities and services at the disposal of their communities, by taking the role of CHCs and fulfilling their six main functions . HoweverIn the last couple of years, people have started to complain about the government's health reform policy. For example, in 2005, the authoritative research institution in China – the Development Research Center of State Council P.R. China – released results indicating that the Chinese health reform program was not successful and failed overall to deliver an efficient and cost-effective health care service to its population. Therefore, the objective of the present study is to discuss the utilization of CHCs, compare them with local hospitals, and determine whether they can deliver appropriate basic medical and public health services ,6.The study was approved by Peking University Health Science Center Institutional Reviewing Board (NO: IRB00001052-T1)All data were collected from CHCs and local hospitals with the assistance of the local health bureaux and were analyzed. In collaboration with members of the community, an initial quantitative assessment was performed to evaluate five medical resource variables: "Average professional income per staff"; "Medical income per 100 Yuan fixed assets"; "Level of person-time charge for outpatient service"; "Proportion of administrative expenditure to total expenditure"; "Average outpatients per staff per day" Table . The medThe initial quantitative assessment design was applied to six cities chosen from regions of South-East China – Guangzhou, Foshan, Shenzhen, Fuzhou, Xiamen and Hangzhou. Three hospitals (1 medium-large and two large) and three CHCs were chosen randomly "by lots", and data samples were collected from the local health bureaux. We have emphasized hospital size in order to indicate patient turnover in the outpatient departments per number of staff per day and the number of patients attending according to their needs, which vary from one hospital to another. The 3 CHCs, chosen randomly from three cities, were almost identical in the size of their facilities. Also, we investigated the utilization of health resources in each city and the standard of living in each community. All data were processed using SPSS software. Analytical methods mainly included descriptive analysis, paired T-tests, one-way ANOVA, etc.  Imperfection of compensatory funds mechanism. The government has clearly pointed out that the CHCs should be constructed within their own street communities as part of urban planning. Every street should provide housing for its CHCs. In practice, this policy is difficult to implement because house ownership and easement are always related to individuals or the interests of certain economic sectors. Since the CHCs are not channeled in accordance with the structure of society, they are institutions without clear status and lack other financing methods; for example, social donations have not reached them. Community health service centers have no single proper and unified standard charges. Charges differ widely between a hospital and a CHC. Sufferers from common diseases can obtain the service they require at the CHCs, but prefer to be treated at large hospitals. Furthermore, the double-way referral means that patients can be transferred from a CHC to a hospital, but not from a hospital to a CHC, even those with mild diseases. Hence, owing to a lack of economic compensation from the government, the CHCs are stressing treatment rather than concentrating on prevention, and this situation is widespread among the community health centers. Moreover, CHCs' expenditure is exceeding income, and they can hardly keep running on this basis [ Imperfec(2) General medical education obviously cannot meet the residents' high demands and expectations. Almost all community doctors come from various types of hospitals with different specialties but lack primary care experience. Since they are trained only for several months in general practice, their specialist field is considered an obstacle in their performance in the CHCs, and sometimes several specialist doctors need to work together on one patient's disease. The CHCs need qualified and certified general practitioners who are considered the "curbstone general practitioners" in general medical practice.(3) Different levels of society have different impressions of CHCs. The recognition of government leaders for these centers is not profound. Also, most residents regard the CHCs as small medical institutions that offer treatment services on the doorstep, but they do not fully understand the CHCs' six main functions. Because residents' health awareness remains weak, they do not realize the importance of the disease prevention and health care functions. When medical personnel pay a home visit in order to perform a health promotion or complete a family health record, a misconception frequently arises; residents think that the CHC personnel might charge for the service or "though no charge now, charge in the future". So they refuse the service that has been offered to them, and this hinders the CHCs' work. Hence, health leaders should have a better recognition and understanding of these issues, and health promotion should concentrate more on education targeting the service users.(4) The CHCs lack experience in the operation and management fields. The institutions' efficiency and performance are affected by heavy bureaucracy: there is a lack of research that could be utilized to tackle problems; an absence of effective assessment methods or system for evaluating management; no institutional incentives such as a staff performance reward or punishment system; and no effective supervisory management system throughout the operation.The government must exert more effort by performing more serious research into residents' health care needs. The central and local governments should take advantage of the information available about peoples' needs and demands in order to develop the service areas by expanding the service connotations plan and making the CHCs develop healthily and continuously.One should take a further step towards perfecting the CHCs' economic compensation methods. Of the CHCs' six main functions, only medical treatment can bring an economic yield. The other five functions have economic yields that are not obvious and they have "welfare" features. The national government proposed that the CHCs' economic compensation channels should include government participation in subsidizing the costs for residents attending the CHCs; direction of part of hospitals' pharmaceutical income towards financing the CHCs; permitting local residents, those holding the medical insurance, to be treated at the CHCs; etc. In future, the government should pay more attention to the CHCs' role when it is considering health cost investment. Currently, the service sectors and the types of treatment within the CHCs differ from what hospitals offer. They have no standardized or a unified charge. To make up for the shortages of funds, the government should exert more effort to formulate unified prices. Each standardized charge should be suitable for the local residents' level of income, economic affordability and medical insurance reforms. The CHCs should be eligible for listing in the urban resident's basic medical insurance expense account, which would help to build a "double-way referral mechanism", i.e., patients with serious diseases should be transferred from the community medical centers to hospitals, and patients with mild diseases should be transferred from hospitals to the CHCs. This will reduce medical expenses as a whole.(1) Build and improve effective management systems for CHCs. Following the basic principle of "government leads CHC, street institution builds stage for CHC, and CHC serves residents", the construction of a management system should channel the CHCs under the government's control. Meanwhile, sufficient consideration should be given to both variables: the industry/profession and the region. It is necessary that a norm for operational management be formulated, specific patterns be followed, and necessary functions be implemented by the community health service, such as an evaluation system and a community health service assessment index. By adopting these two evaluation scales, the CHCs will be more standardized and normalized.(2) Strengthening the construction of the CHCs' professional staff. Currently, according to the government's proposals and requirements, every CHC should serve 2000 to 4000 people and should have a general practitioner (GP). There is an urgent need to implement a scheme to train high qualified and accomplished GPs. Another important issue is that, when we select and allocate community health service personnel, we should pay more attention to their formal schooling, major, knowledge, age, professional job title, etc. Those with current low professional job titles and low formal schooling should be replaced by highly qualified staff. Since general medical education is considered the core of medicine, post training is considered essential. Current and future community health service workers should receive standard post training and should be licensed to work after they have passed the assessment tests. By adopting this set of standards, the quality of the general service will gradually be improved. We should emphasize the work performance reward and punishment system, linking performance with placement and job titles with promotion, in order to stimulate initiatives among the medical care workers serving the communities.3) Implement promotion and continuous medical education at different levels. With the new health service reforms, the CHCs require the wholehearted support of society as a whole and broad participation from residents living within their communities. Lobbying and promoting widely will push the leaders to change their way of thinking and strengthen their goals towards the construction of CHCs. The central and local health authorities should institute further promotion and implement further continuous education for the medical staff. Also, when evaluating the performance of CHC medical staff, their attitude towards patients should take "biological-psychological-social behavior" into consideration [ ImplemenEfficient essential health care should be available to everyone. The local hospitals and the CHCs are considered the main care providers for local residents. It is important to put the six functions of the CHCs into effect and build a new and safe community health care network ,5.However, there are some problems in realizing the functions of the CHCs:(1) CHC services are far from understood. The rates of awareness about Community rehabilitation, Health care service and Health education are 42.2%, 35.3%, 31.8%, respectively. These functions are not fully realized or completely utilized.(2) At present, the CHCs' main function is "medical treatment service", and the awareness rate of "Medical treatment service" is the highest (98.6%). However, the rate of "Satisfaction about the item" is the lowest (21.9%).(3) As a whole, the utilization of medium-large to large hospitals is generally higher than that of CHCs. Residents prefer to attend local hospitals whether their diseases are serious or not. This has led many people to complain about the service, described by the Chinese Ministry of Health as "difficult to see doctor" and "expensive to see doctor" in some hospitals ,5,6.To sum up: we need to increase the promotion of health education towards residents; try to change the residents' perception and recognition of health care; try to understand the concept of health consumption by making the CHCs' six service functions suitable for people who have high expectations and demands for appropriate health care; and make the community health service function better.The author(s) declare that they have no competing interests.*Corresponding authors*Prof PX designed the study, carried out the field work and wrote the initial draft.*Dr. HD analyzed the data and guided and supervised the design and participated in writing and finalizing the paper. Both authors read and approved the final manuscript. WX performed field work, collected the data and participated in its statistical analysis. ZH performed field work, collected the data and participated in its statistical analysis.The pre-publication history for this paper can be accessed here:


Preventing Chronic Disease provides in-depth examinations of the purposes and uses of health education programs. We thank Neil Hann of the Oklahoma State Department of Health and Carol Russell of the Directors of Health Promotion and Education for serving as guest editors for this issue.Health education is an innate aspect of public health practice and difficult to discuss as a separate entity. Nevertheless, this special issue of Among the earliest recorded health education programs in the United States were those related to military troops of the 18th century during the Revolutionary War. These programs are distinguished by their recognition of a "community," determined as much by membership in a common group as by geopolitical boundaries. Soldiers were more likely to die of infectious diseases than of battle wounds; camp hygiene was thus a critical aspect of an officer's duties. One of George Washington's first general orders, dated July 4, 1775, states, "All officers are required and expected to pay diligent Attention to keep their Men neat and clean . . . and inculcate upon them the necessity of cleanliness. . . . They are also to take care that Necessarys [latrines] be provided in the camps" (promotores to serve as community health educators in neighborhoods (Several programs discussed in this issue highlight health education in communities. A report from Texas describes the certification of borhoods . Oregon borhoods . Coloradborhoods . North Cborhoods , and in borhoods .Report of the Sanitary Commission of Massachusetts 1850, also called the Shattuck Report after the chairman of the commission, Lemuel Shattuck (One of the most remarkable reports on public health in the 19th century was the Shattuck . This dohealth. . . . This matter has been too little regarded in the education of the young. Intellectual culture has received too much and physical training too little attention. . . . By adopting [the recommendation], many and many a life would annually be saved in this Commonwealth, and the general health of the rising generation would be greatly improved" (One of the recommendations of the Shattuck Report addressed school health education: "Every thing connected with wealth, happiness and long life depends upon mproved" .The health of school-aged and preschool-aged children receives noteworthy attention in this issue. Rhode Island surveyed school principals to assess current health promotion programs and then investigated the use of the School Health Index to improve school programs . WisconsThe Shattuck Report also recommended that "open spaces be reserved, in cities and villages, for public walks; that wide streets be laid out; and that both be ornamented with trees." The primary reason for this recommendation was to purify the air, but the report stated, "Open spaces also would afford to the artizan and the poorer classes the advantages of fresh air and exercise, in their occasional hours of leisure" .In this issue, West Virginia describes a physical activity promotion project that encouraged schools, students, and communities to conduct small research programs in physical activity . Many ofEarly in the 20th century, the Children's Bureau, a unit within the federal Labor Department, embarked on a massive media campaign, distributing 3 million pamphlets on infant care between 1914 and 1925 and responding to up to 125,000 letters each year from mothers (Media campaigns continue to be an important aspect of health education. Oregon analyzed data from the Behavioral Risk Factor Surveillance System to identify whether at-risk Oregonians knew they were at high risk for developing diabetes . KnowledIn the 21st century, we continue to face similar challenges on health education, but we have new tools. Alabama describes an innovative approach to analyzing cancer data, which uses geocoding, a recently developed information tool, to identify unique population segments . In a coSuch a plethora of technical opportunities to collect and combine data was not available a decade ago. The multiple, unique programs presented in this issue illustrate the progress of U.S. health education over the past 230 years. While we have not yet achieved the goal of healthy lives for all, we have good reason to expect additional success in the future.