Verbal autopsy (VA) is an established tool for assessing cause-specific mortality patterns in communities where deaths are not routinely medically certified, and is an important source of data on deaths among the poorer half of the world's population. However, the repeatability of the VA process has never been investigated, even though it is an important factor in its overall validity. This study analyses repeatability in terms of the overall VA process ), as well as specifically for interview material and individual causes of death, using data from Burkina Faso and Indonesia.Two series of repeated VA interviews relating to women of reproductive age in Burkina Faso (n = 91) and Indonesia (n = 116) were analysed for repeatability in terms of interview material, individual causes of death and CSMFs. All the VA data were interpreted using the InterVA-M model, which provides 100% intrinsic repeatability for interpretation, and thus eliminated the need to consider variations or repeatability in physician coding.The repeatability of the overall VA process from interview to CSMFs was good in both countries. Repeatability was moderate in the interview material, and lower in terms of individual causes of death. Burkinabé data were less repeatable than Indonesian, and repeatability also declined with longer recall periods between the death and interview, particularly after two years.While these analyses do not address the validity of the VA process in absolute terms, repeatability is a prerequisite for intrinsic validity. This study thus adds new understanding to the quest for reliable cause of death assessment in communities lacking routine medical certification of deaths, and confirms the status of VA as an important and reliable tool at the community level, but perhaps less so at the individual level. Garenne and Faveau  recentlyIn this paper, we report the results of a study designed specifically to examine the repeatability of the VA process. The study was run in parallel in Burkina Faso and Indonesia, to allow comparison between two very different settings, both of which involved repeated VA interviews concerning deaths among women of reproductive age. We chose to exclude consideration of repeatability of the interpretation stage of the process, by using the InterVA-M model , which gOur major aim was to assess the repeatability of the overall VA process under operational conditions, from interview to aggregated mortality patterns, in the two different settings.Subsidiary aims were:1. to assess the repeatability of the interview stage of the VA process ;2. to assess the repeatability of cause of death determination at the individual level;3. to assess the repeatability of cause-specific mortality fractions (CSMF) determined at the population level.It should be noted that this study did not aim to arrive at conclusions, other than on repeatability, about cause of death patterns in either setting, and not explain differences in mortality patterns between the two countries, evaluate the clinical validity of VA, nor draw conclusions for health planning.In both Burkina Faso and Indonesia, large scale community-based surveys of mortality among women of reproductive age, with a particular focus on pregnancy-related mortality, were undertaken in 2005–6 (February to May 2006 in Burkina Faso and December 2005 to June 2006 in Indonesia) ,16. ThesThe interview material thus consisted of individual sets of responses to the 75 possible InterVA-M indicators, and the repeatability of the interview stage of the overall process was assessed by calculating kappa statistics for each indicator, together with p-values assessing whether agreement between the original and follow-up interviews was significantly greater than that expected by chance.The InterVA-M model was then run on all the original and follow-up interview material from both countries, to interpret likely pregnancy status and cause-of-death outcomes. The InterVA-M model generated, for each case, the most likely pregnancy status at the time of death  with an associated likelihood. Then up to three likely alternative causes of death were generated, each with an associated likelihood. These likelihoods were used to ascribe fractional causes of death, as described previously . As the The individual pregnancy status and cause of death outputs were then combined into overall pregnancy status fractions and CSMFs for the population samples in Burkina Faso and Indonesia respectively, which were then compared in terms of magnitude and rank order.Ethical approvals for the verbal autopsy studies in Burkina Faso and Indonesia, including follow-up interviews where needed, were granted by the Ministry of Health National Health Research Ethics Committee  and Centre MURAZ Institutional Review Board ; by the Faculty of Public Health Research Ethics Committee at the University of Indonesia .A total of 207 VA interviews were successfully repeated, 91 in Burkina Faso and 116 in Indonesia. The basic characteristics of these cases (both the deceased women and the interview respondents) are summarised in Table Kappa statistics were calculated for each InterVA-M indicator in each country to assess the repeatability of the verbal autopsy interview process. The distribution of kappa statistics for all measurable InterVA-M indicators in relation to their positive response rate in each country are shown in Figure Since recall period is obviously a potentially important factor in the repeatability of VA interviews, mean kappa statistics were also calculated separately for original interviews falling before or after the median recall time, for each country. In Burkina Faso the median time to first interview was 26 months, and for 51 indicators represented in interviews on both sides of the median, the mean κ was 0.27 for interviews up to and including the median, compared with 0.17 for interviews after the median. Of the 51 indicators, 76% had a lower κ value for interviews beyond the median recall time. In Indonesia, the median time to first interview was 7 months, and for 60 indicators the mean κ was 0.44 for interviews up to and including the median, compared with 0.45 for interviews after the median time.Table Table Table The concept of VA, from the interview, through interpretation, to population-level results, is a complex one. This study has investigated the repeatability of three different stages of this overall process, which is entirely novel, and capitalised on the use of the InterVA-M interpretative model in order to eliminate any subjective or inter-country variation in the process of interpreting the VA interview material.It is difficult to discuss these findings extensively in relation to other work, since very little attention has previously been given to the repeatability of VA. All of our interviews were conducted in real field conditions, typical of settings in which VA is an important tool, and where deaths in hospital are rare. We happened to use material relating to women of reproductive age, although it is likely that similar findings would apply to other population groups. While it is possible that we may have influenced the conduct of the VA process by, exceptionally, undertaking follow-up interviews, we believe this is unlikely. In all cases the interval between the original and follow-up interviews was between one and two years, which probably minimised any effect associated with recalling the previous interview, even where the same respondent was involved. On the other hand, the additional accumulation of recall time since the death itself may have influenced the way in which original events were remembered, and thus reduced repeatability.In terms of the repeatability of the VA interview stage, it is clear that there were major differences between the interviews undertaken in Burkina Faso and Indonesia, with a markedly higher mean kappa statistic and proportion of indicators with non-chance agreement in Indonesia Figure . We cannWhen the individual-level pregnancy status and cause of death outputs were compared between the original and follow-up interviews, there was a disappointing lack of concordance, though this was perhaps not surprising given the extent of non-agreement between the interview material, particularly from Burkina Faso Table . This fiHowever, when the output data were considered at the population level, there was a much clearer sense of agreement between the original and follow-up material Table . As mighTaking a public health perspective, Table The relative levels of repeatability, both between the two country settings involved and between the different stages of the VA process, are interesting. The obvious differences between the two countries make clear that the whole VA process is context-dependent, since it might reasonably be inferred that in a context where repeatability is lower, then the intrinsic validity of one-time interview material would also be lower. The effects of non-repeatability at different stages of the VA process are also interesting – our results suggest that, given moderate repeatability within the original interviews, the repeatability of cause of death at the individual level is seriously compromised. However, when a reasonable group of individual VAs are taken as aggregate entities (around 100 per setting in these results) then our findings suggest that there is some recovery of repeatability, certainly to levels that appear to be acceptable in terms of generating aggregate data for health planning. The effects behind this are not easy to quantify, but it seems likely that some of the non-repeatability of details at the interview stage may have the effect of tipping the balance between possible causes at the individual level, but with many such differences then cancelling out on aggregating causes to the population level.Repeatability is often not explicitly assessed for health measurement tools – so why is it important in relation to VA and what do the results tell us? The origins of VA – as a proxy source of cause of death data in the absence of medical certification – has sometimes led to confusion about its fundamental nature. While it is not generally argued that VA should be used as a direct replacement for medical certification at the individual level, this principle has not always been made explicit in VA work. Consequently, attempts to validate VA -13 have We therefore offer these analyses of VA repeatability as a fresh viewpoint on the overall process, to shed some light on the practice of VA under realistic operational conditions and the value of the ensuing results. This partly follows from our previous consideration of the question "Who needs cause of death data?" , since VAt least in contexts emphasising community-level cause-specific mortality, the findings of these repeatability analyses are encouraging. Although good repeatability does not guarantee good validity, at least it suggests that intrinsic validity is not compromised by random effects in the overall process. It also became clear that the longer recall periods associated with some of the Burkinabé interviews were detrimental to repeatability – and so presumably to validity. At the same time, overall repeatability was lower in Burkina Faso than in Indonesia, possibly because of different respondent profiles, which again emphasises the importance of considering VA material contextually, rather than simply in terms of standardised methods.The overall process of VA, from interview to CSMF, has been shown to have good repeatability for two very different communities. However, VA outcomes were less repeatable at the individual level, and recall periods beyond two years compromised repeatability. Although repeatability does not demonstrate validity, it is a prerequisite, and so this study adds new understanding to the quest for reliable cause of death assessment in communities lacking routine medical certification of deaths.The authors declare that they have no competing interests.PB devised the study; all authors participated in field work; MO and SNQ coordinated work in Burkina Faso and Indonesia respectively and prepared datasets; PB & LD carried out analysis and drafting.Repeatability of VA indicators in Burkina Faso. Details of repeatability for each verbal autopsy indicator from a series of 91 repeated interviews in Burkina Faso .Click here for fileRepeatability of VA indicators in Indonesia. Details of repeatability for each verbal autopsy indicator from a series of 116 repeated interviews in Burkina Faso .Click here for file


During the past century, humans have gained more years of average life expectancy than in the last 10,000 years; we are now living in a rapidly ageing world. The sharp rise in life expectancy, coupled to a steady decline in birth rates in all developed countries, has led to an unprecedented demographic revolution characterized by an explosive growth in the number and proportion of older people. Ageing is a complex process that negatively impacts the development of the immune system and its ability to function. Progressive changes in the T and B cell systems over the life span have a major impact on the capacity to respond to immune challenge. These cumulative age-associated changes in immune competence are termed Immunosenescence: some immunological parameters are commonly notably reduced in the elderly and, reciprocally good function is tightly correlated to health status. Hence, a better understanding of Immunosenescence and the development of new strategies to counteract it are essential for improving the quality of life of the elderly population. The "Understanding Aging: Biomedical and Bioengineering Approaches" conference was held from June 27–29, 2008 at UCLA organized by Aubrey de Grey to discuss and talk about possible intervention in ageing.During the past century, mankind has gained more years of average life expectancy than in the last 10,000 years. We are now living in a rapidly ageing world. The sharp rise in life expectancy, coupled to a steady decline in birth rates in all developed countries, has led to an unprecedented demographic revolution characterized by an explosive growth in the numbers and proportion of older persons. Nowadays, people are living much longer than they used to and the longer they live, the longer their bodies are exposed to environmental factors which increase the risk of age-associated diseases. The reduction of the response to environmental stimuli is associated with an increased predisposition to illness and death. This progression causes a reduction of the response to environmental stimuli and, in general, is associated with an increased predisposition to illness and death. In Western countries, the mortality rate increases in people over 65 years, if compared with individuals between 25 and 44 years old, by 100-fold for stroke, as well as chronic lung disease, 92-fold for heart disease, 89-fold for pneumonia and influenza, 43-fold for cancer [In senescence alterations of innate and instructive immunity have been described. The modifications of the immune system in the elderly are generally evaluated as a deterioration of the immune system, this is the origin of the term immunosenescence. A good immune system in the elderly is tightly correlated to health status, and some immunological parameters are often notably reduced in the elderly. On the other hand infectious diseases, tumors, autoimmune phenomenona and inflammatory chronic diseases like atherosclerosis and Alzheimer's disease, are frequent in this phase of the life course -5.A body of experimental and clinical evidence has suggested that the immune system is implicated, with a variable degree of importance, in almost all age related or associated diseases. Both innate and instructive immune systems are usually involved in the pathogenesis of these chronic diseases. However, innate immunity appears to be the prevalent mechanism driving tissue damages associated with different age-related diseases . So, ageHere is an extract of the talks and posters presented:Perturbation of mitochondrial Fe homeostasis cause a decline in mitochondrial function that causes neuromuscular degenerative disease and other tissue dysfunction. C. Leeuwenburgh suggested that mitochondrial non-heme Fe represents a potential novel target for targeted interventions to slow ageing  .It was proposed that inadequate micronutrient intake leads to metabolic modification that has long term consequences such as cancer (DNA damage), severe infection (immune dysfunction) and cognitive dysfunction and accelerated ageing . Much evidence supports the idea that micronutrient shortage accelerate ageing  .The shortening of telomeres is supposed to be the molecular clock of ageing; indeed there is a strong correlation between age and telomere length and shorter telomeres directly correspond to shorter human life expectancy. For this purpose, several biotech organizations have accepted the challenge of finding ways to prevent telomere shortening by transiently inducing the activity of telomerase . Another research has shown that therapy acting on the catalytic component of human telomerase, such as TAT2, a small molecule telomerase activator, could stabilize the telomere length and retard the loss of the immune control over viral infection  .On the immunological side Dr Z. Cui has shown that cancer cells in vitro could be killed by the effector cells of the innate immune system such as macrophages and neutrophils. A similar activity was discovered in some healthy people concerning granulocytes and monocytes  .According to the fact that the immune system plays an important role in ageing, the group of Prof. C. Caruso, actively involved in immunosenescence studies -5, has dIt is well known that change in immune function are hallmarks of ageing and the group of Dr. A. Agrawal  has shown that the reactivity of dendritic cells to self-antigens can be characteristic of ageing features. Furthermore, this over-reactivity induces lymphocyte T proliferation with subsequent higher risk of autoimmune diseases .Interestingly, Effros's group suggests a possible involvement of hyper-activated T cells in bone loss associated with vascular disease in aged mice. The increased proportion of CD8 T cells lacking expression of the co-stimulatory receptor CD28 leads to decreased vaccine responsiveness and early mortality . ST PariAgeing is a complex process that negatively impacts the development of the immune system and its ability to function. Progressive changes in the T and B cell systems over the life span have a major impact on the capacity to respond to immune challenge. These cumulative age-associated changes in immune competence are termed immunosenescence. A better understanding of immunosenescence and the development of new strategies to counteract it are essential for improving the quality of life of the elderly population The authors declare that they have no competing interests.All authors contributed equally to the paper and read and approved the final manuscript


Providing palliative care is a growing priority for health service administrators worldwide as the populations of many nations continue to age rapidly. In many countries, palliative care services are presently inadequate and this problem will be exacerbated in the coming years. The provision of palliative care, moreover, has been piecemeal in many jurisdictions and there is little distinction made at present between levels of service provision. There is a pressing need to determine which populations do not enjoy access to specialized palliative care services in particular.Catchments around existing specialized palliative care services in the Canadian province of British Columbia were calculated based on real road travel time. Census block face population counts were linked to postal codes associated with road segments in order to determine the percentage of the total population more than one hour road travel time from specialized palliative care.Whilst 81% of the province's population resides within one hour from at least one specialized palliative care service, spatial access varies greatly by regional health authority. Based on the definition of specialized palliative care adopted for the study, the Northern Health Authority has, for instance, just two such service locations, and well over half of its population do not have reasonable spatial access to such care.Strategic location analysis methods must be developed and used to accurately locate future palliative services in order to provide spatial access to the greatest number of people, and to ensure that limited health resources are allocated wisely. Improved spatial access has the potential to reduce travel-times for patients, for palliative care workers making home visits, and for travelling practitioners. These methods are particularly useful for health service planners – and provide a means to rationalize their decision-making. Moreover, they are extendable to a number of health service allocation problems. Providing palliative care has become a priority for health system administrators worldwide. In many countries, existing palliative care service delivery is inadequate and challenged by population aging, resulting in strained services that are increasingly unable to keep up with demand -4. ThereThe equitable provision of health care services  in an accessible fashion is a primary concern for health planners; however, 'access' can be defined in many different ways. Access to health services can, for example, refer to: availability in terms of socio-economic status or geographic location, the availability of information, wait-list times, and quality of services offered ,14,15. HThe influence of location and distance to health services on health outcomes are well documented -21. Homeet al. [Canadian health organizations have expressed the need to research the geographic and demographic factors that influence palliative care delivery and uptake ,28. GIS-et al.  validateIn Canada, provincial health systems are obligated to ensure access to health services for all citizens, based primarily on the principles of 'universality' and 'accessibility' which are enshrined in the Canada Health Act . GIS metThere is no single, universally accepted understanding of what palliative care services or practice entail ,35. ThisThe vagaries associated with palliative care can act as roadblocks to the effective promotion and delivery of quality end-of-life care . What isPalliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.et al. [Based on suggestions from the European School of Oncology, Ahmedzai et al.  refined Basic palliative care is the standard of palliative care which should be provided by all healthcare professionals, in primary or secondary care, within their normal duties to patients with life-limiting disease.Specialised palliative care is a higher standard of palliative care provided at the expert level, by a trained multi-professional team, who must continually update their skills and knowledge, in order to manage persisting and more complex problems and to provide specialised educational and practical resources to other non-specialised members of the primary or secondary care teams. If a patient has difficult symptoms which cannot be controlled by his/her current healthcare team, he/she has a right to be referred, and the current healthcare provider has an obligation to refer, to the local palliative care team. [re team. This distinction between basic and specialized care is useful to categorize the different types of care and locations of palliative care service delivery. Care that is delivered by general practitioners, some allied health professionals, and informal caregivers in home and acute care settings can be considered basic palliative care. Multi-focal care which is delivered by a multi-disciplinary team with some palliative care specialization in a variety of settings including the home constitutes SPC. Patients receiving SPC often have access to a wider variety of specialist treatments and support, from comfort care to intense pain management, while their families can access a host of services that can include respite care, counselling and bereavement services. These services are provided by specially trained experts, which helps to ensure the best possible quality of death and dying for patient and support for the family during the palliative stage.et al. [Albeit not definitive, studies have found that SPC is more effective at improving patients' quality of life in their final days than basic palliative care -45. Alsoet al.  found thet al. ,48. Ensuet al. . ReasonsThe purpose of this study is to model spatial accessibility to palliative care in British Columbia using the SPC definition. Accessibility is determined through calculating the proportion of the total population that is within a reasonable travel-time to a SPC location. Also, geographically distant communities without SPC services are highlighted as potential candidate locations to provide SPC to surrounding rural and remote areas. The SPC definition was chosen because it provides a standard of comparison for future spatial analyses of palliative care services in other countries and regions. Furthermore, it provides a framework for our future research goals of determining appropriate locations for siting regional hubs of palliative care to serve the rural and remote regions highlighted by this study. These hubs will boast multi-professional teams to deliver SPC and will have the ability to educate local practitioners and caregivers in remote areas to provide good-quality basic palliative care where SPC is not feasible.This study calculates the service areas or catchments of existing SPC locations in BC and the populations within those service areas. At the same time, the study identifies and calculates populations outside one hour to SPC. In addition, proportions of the population within and without the service catchments are calculated. The locations of current SPC services in the province were collected by directly contacting each of the five regional health authorities. The locations that adhered to this definition included hospice residences and designated palliative care units within hospitals with a minimum of five beds. Five beds was considered the minimum for a hospital palliative unit because it was expected that this would also mean the unit would have access to a multi-disciplinary team of palliative experts. Some smaller hospitals in BC set aside one or two beds for palliative patients on an as-needed basis, though care for these patients is typically provided by non-specialized volunteers and practitioners, and as such, do not meet the criteria for SPC. Thus, the number of beds was used as a proxy indicator for the presence of an on-site multi-disciplinary team of palliative care specialists and not an indicator of palliative care supply.Locations of SPC services in each of the five BC health authorities were geocoded and mapped using ArcGIS 9.2 . To creaet al. [2) that had centroids within 2500 metres of the catchments.To determine the population within each catchment, a spatial query method was employed using census block-level population data , the finet al.  describeAccording to our working definition at the time of the analysis there were 29 locations where SPC was delivered in BC and three new locations slated to open in the near future. The sites of delivery included hospice residences and palliative care units in hospitals, each with varying capacities. Figure Table All of the Urban Areas greater than one-hour from SPC services are highlighted in Figure Several larger regional centres are without access to SPC. Table We have undertaken a spatial analysis of spatial access to SPC services in BC. Figure At first glance, it appears that the spatial accessibility of SPC in BC is reasonably good, with over 81% of the province's population residing within one hour from at least one service location. Whilst this is true, spatial access varies greatly by health authority as illustrated in Table By determining areas that are outside of the catchments, we can identify regions for which health system administrators should consider siting further SPC services in the province. Figure Use of the SPC definition care may discount the efforts of informal caregivers and non-specialized types of care which also likely benefit the patient at the end-of-life. However, despite focussing on specialized care, this study does acknowledge the need for basic palliative care in some communities where SPC is not available or feasible. Another potential limitation was the fact that the supply side was considered to be equal among centres, and demand for SPC was not addressed. Several GIS modelling types are available which take supply and demand into consideration; however, these methods are not appropriate for palliative care. Supply is usually measured as the number of care beds or number of physicians. As palliative care consists of a diverse set of therapies and interventions delivered in a multitude of settings, it is likely impossible to determine the exact supply of services for any given area. In terms of demand, we assumed the whole population of the study area to be potential users of SPC. This is a reasonable assumption given that this type of care is now targeting all age groups; the only restriction is that a patient must have a life-limiting condition.Possible limitations regarding the use of one hour as a reasonable travelling distance to services are apparent. This travel-time was chosen because of its importance within emergency services as the 'golden hour', the period of time in which patients in need of emergency care should arrive at hospital to minimize the risk of serious consequences ,54. One It is likely that numerous individuals at end-of-life living in communities significantly outside of the one-hour catchments either die without receiving SPC, are forced to commute an unreasonable distance to get to non-local/regional service sites, or relocate to larger urban centres that have existing SPC. Relocation, however, is often against the wishes of patients and their families and runs counter to the trend of ageing-in-place in rural and remote BC communities . FurtherAccording to our model, close to three quarters of a million people in BC  lack access to SPC, and in general, spatial access is non-existent for people who do not live in the Vancouver region or the larger urban centres on Vancouver Island and in the province's interior. Unique challenges exist in delivering a full complement of health and social services in rural and remote BC . PolicieProviding equitable spatial access to good quality palliative care is a growing priority for health systems worldwide. Distance and location in part determine utilization of services and influence health outcomes. Unique challenges for palliative care delivery exist in BC as a result of the large rural and remote areas where services are often limited, and distance to locations with specialized services are great. GIS methods can be used to model health service catchments, thereby highlighting the populations that have access to care. This study used a vector GIS-based method to identify areas of BC that are within one hour travel-time to SPC services and the proportion of the population in each provincial health authority that existing services reach. A working definition of palliative care was formulated to facilitate the modelling and analysis, and to promote further spatial analyses of palliative care. Also described were the communities that are more than one hour from services.Using the working definition, 29 existing SPC and three future locations  were identified. Creation of catchments for all 32 locations illustrates that over three-quarters of BC's residents are within one-hour drive to SPC. However, distribution varies greatly by health authority, ranging from just 36% in the NHA to 95% in the FHA. A majority of the communities outside of the one-hour catchments are located in either the NHA or IHA. The larger  and more clustered communities  are posited to be potential locations where new SPC services could be implemented to improve spatial access for those residing in local rural and remote areas. Current and future locations of such services should focus on delivery, education, and regulation of SPC.Strategic location analysis methods must be developed and used to accurately locate new SPC services to in order to provide spatial access to the greatest number of people. Specifically, more research is needed into the factors and constraints that ultimately determine the suitability of locations to host SPC than what is provided in the present study. Characteristics of future locations that should be considered include: the presence of other health services and infrastructure, availability of support services, and population demographics, among other factors. Such consideration will work to ensure that limited health resources are allocated wisely.Whilst the information gleaned from this study is important for planning of palliative care services, the methodology is also extendable to other health services. It provides a means of rationalizing service allocation based on maximizing the number of people served within a designated road travel time.SPC: specialized palliative care; BC: British Columbia; IHA: Interior Health Authority; FHA: Fraser Health Authority; NHA: Northern Health Authority; VIHA: Vancouver Island Health Authority; VCHA: Vancouver Coastal Health Authority; WHO: World Health Organization; GIS: geographic information systems.The authors declare that they have no competing interests.JC conducted the spatial analysis and wrote the first draft of the manuscript. NS conceptualized and developed the methodology, and assisted in writing and editing the manuscript. VAC provided domain expertise in palliative care and health services and assisted in writing and editing the manuscript.The pre-publication history for this paper can be accessed here:


Medical tourism is understood as travel abroad with the intention of obtaining non-emergency medical services. This practice is the subject of increasing interest, but little is known about its scope.A comprehensive scoping review of published academic articles, media sources, and grey literature reports was performed to answer the question: what is known about the patient's experience of medical tourism? The review was accomplished in three steps: (1) identifying the question and relevant literature; (2) selecting the literature; (3) charting, collating, and summarizing the information. Overall themes were identified from this process.n = 176). A further 57 sources were included for review after hand searching reference lists. Of the 348 sources that were gathered, 216 were ultimately included in this scoping review. Only a small minority of sources reported on empirical studies that involved the collection of primary data (n = 5). The four themes identified via the review were: (1) decision-making ; (2) motivations ; (3) risks ; and (4) first-hand accounts . These themes represent the most discussed issues about the patient's experience of medical tourism in the English-language academic, media, and grey literatures.291 sources were identified for review from the databases searched, the majority of which were media pieces  understanding how multiple information sources are consulted and evaluated by patients before deciding upon medical tourism; (2) examining how patients understand the risks of care abroad; (3) gathering patients' prospective and retrospective accounts; and (4) the push and pull factors, as well as the motives of patients to participate in medical tourism. The findings from this scoping review and the knowledge gaps it uncovered also demonstrate that there is great potential for new contributions to our understanding of the patient's experience of medical tourism. Medical tourism is becoming an increasingly popular option for patients looking to access procedures  that are seemingly unavailable to them in their home countries due to lack of affordability, lack of availability, and/or lengthy waiting lists, among other reasons ,2. In itThe practice of medical tourism does not exist without criticism, particularly when involving patients from developed nations going to developing nations for procedures. It is thought to contribute to the commodification of health and health care by allowing those with the financial means to do so to purchase care that may be unavailable to other citizens . The praAlthough estimates of the number of patients engaging in medical tourism each year vary widely, ranging from millions to tens of thousands, there has been speculation that growth in the industry will continue in the coming years -13. Giveindependently  for care internationally, those who are sent abroad by their home systems in order to access specialized care that is not available locally, and those who live in border regions with traditions of sharing care across borders ; mRetrospective, post-recovery reports were abundant in the media sources reviewed. In these accounts former medical tourists reflect, overwhelmingly positively, on their experience overall and the positive impact that receiving a procedure abroad has had for their health. A former Canadian medical tourist had this to say: "Life is too precious. I'm in my early 50s and I have lots of things to do in my life and one of them isn't lying at home in pain... I'm a Victoria firefighter. I have been for 29 years and I don't want to retire that way, you know, with a disability" (n.p.) . AccessiTable From the sources reviewed for this scoping review it can be understood that patients are likely to hold significant responsibilities in the practice of medical tourism. For example, informational continuity of care is a quality indicator and is established through patient information being available over time and to multiple practitioners in different locations ,106. WhiAnother responsibility is that it may be advisable for patients to take active measures to avoid encountering risks when traveling and also while abroad. While all patients run the risk of being exposed to any number of health threats when receiving surgery, such as surgical site infections and clotting complications ,109, theThis scoping review has revealed that the patient's experience of medical tourism might not end upon returning home, nor begin at the point of departure. In fact, it can extend far in advance of and beyond when care is received. The law reviews examined have focused extensively on the fact that there is typically little legal recourse for patients accessing surgeries and other procedures abroad in countries with weak malpractice laws. For patients who experience negative outcomes, their pursuit of compensation, whether financial or otherwise, may draw on over an extended period of time, quite possibly with little result, extending well beyond the post-operative recovery period.It was noted in the findings section that word-of-mouth is likely to be important within the medical tourism industry: satisfied patients can spread information about facilities and destination countries to interested others. In this way, these medical tourists may become 'ambassadors' for destination countries and hospitals over time after returning home. In doing so they may effectively challenge perceptions of the health care delivered in some countries, thus working to overcome the kinds of 'straw hut' perceptions of care shared in the first-hand accounts subsection. At the same time, negative experiences of care abroad may serve to further entrench these perceptions.Although a significant number of sources were accepted into this scoping review, the vast majority did not present empirical research or other tested facts. Instead, this review has revealed that most of what is known about the patient's experience of medical tourism is, in fact, speculative, idea-based, or anecdotal in nature. The frequency with which some things were reported in the sources reviewed, such as cost savings as being a significant motivator for patient engagement and waiting lists pushing patients abroad, suggests that there is some consensus about specific aspects of the patient experience. However, often authors looked to media sources to verify such aspects given that empirical evidence is lacking. This is not surprising as newspaper and magazine articles were found to be some of the only sources that shared first-hand accounts from medical tourists, thus allowing for limited confirmation about ideas regarding motivations and other factors central to the patient's experience. Put another way, the area of medical tourism is ripe for research to be conducted by social and health scientists alike from a range of disciplinary and methodological perspectives. Research is needed not only to confirm or refute long-standing speculation regarding the patient's experience, but also to 'shed light' on areas that have been given almost no consideration to-date. For example, it seems that little attention has been paid to establishing the size and directions of the international flow of patients or the success rates of procedures performed at medical tourism hospitals. No doubt data access is a challenge, in that private hospitals treating international patients are likely reluctant to share such information.A number of specific knowledge gaps are evident within the four thematic areas regarding the patient's experience of medical tourism identified in the scoping review. Research attention needs to be given to understanding how information sources consulted and evaluated by patients prior to departure. It would also be useful to better understand how patients understand the risks of accessing care abroad at this point in time. Retrospective accounts upon returning home could then shed light onto whether or not important factors were adequately considered in advance of ultimately deciding on accessing care abroad. Such research could offer useful insights into what patients need to know before going abroad and could ultimately assist with developing patient-focused decision-making aids. Significant knowledge gaps also exist regarding the push factors, pull factors, and motivations identified in the scoping review. Research needs to be conducted to confirm that those factors cited by the sources reviewed are indeed accurate, and also to determine whether or not others exist and also how they might differ between individuals and also patient groups . In fact, any research that contributes to enhancing our understanding of how experiences of medical tourism differ between patients and the roles of factors such as socio-economic status, diagnosis, and overall health status in such differentiation is highly needed.It was noted at the outset of this section that multiple individuals and groups are involved in shaping the patient's experience of medical tourism. As such, it is essential to turn research attention to these important stakeholders so as to better contextualize how patients experience this practice. This could include investigating doctors' and facilitators/brokers' roles in assisting patients during the decision-making process and also in sharing information on the risks. The practice of medical tourism holds significant implications for the airlines that transport patients and also travel agents who do bookings for patients not using the services of facilitators/brokers. There was almost no discussion of these important stakeholders in the sources reviewed in this scoping review. An understanding of the perspectives of these businesses and others who are linked to the industry  on the soundness of the practice of medical tourism and the ways in which it strengthens and/or threatens their operations is needed. This research would also be valuable because so very little consideration has been given to the tourism aspect of medical tourism. Because of this oversight, little is known about the importance of the tourism aspects of travel and decision-making, among other factors, for medical tourists. Tourism scholars, thus, have the ability to make important contributions to this area of health services knowledge.A comprehensive approach was taken to scoping a variety of sources to synthesize what is known about the patient's experience of medical tourism. The inclusion of steps such as having two reviewers for every full source, developing a search strategy in consultation with a librarian, and searching for sources of all types from a comprehensive grouping of databases have added rigour to the scoping process and thus serve as strengths. However, two main limitations exist. The first is that only English-language sources were retrieved and reviewed. No doubt there is literature on medical tourism that has been produced in other languages. At the same time, there were very little non-English-language sources cited in the pieces reviewed, and so this suggests that the most important sources may be available in English. For example, industry and government reports produced in non-English-speaking countries were commonly available in English and so were included in the review process . The sedecision-making in terms of push and pull factors, as well as the consultation of information; (2) motivations related to procedure, travel, and cost; (3) risks associated with patients' health, travel, and pre- and post-operative conditions in the home country; and (4) first-hand accounts of the positive and negative components of medical tourism, sensationalized issues, and post-recovery life. Using insights gleaned from the scoping review, we suggest that medical tourism is likely to have significant implications for patients, including that patients may very well hold a number of responsibilities should they choose to engage in intentionally going abroad for non-emergency care that is paid for out-of-pocket. Among these is potentially playing a role in ensuring that continuity of care is maintained as best as possible despite the disjuncture in their care trajectory across countries and providers.Given the burgeoning, complex, and frequently controversial phenomena associated with medical tourism, this article has presented a much-needed scoping review to illustrate what is known (and not known) about this practice, especially in terms of patients' experiences. Addressing multiple types of literature, we hope this comprehensive knowledge synthesis will usefully guide research, government, and industry agendas alike. Seeking a focused understanding of medical tourism, full review of the 216 included sources  identified four main themes that summarize what is known about the patient's experience. These themes are characterized by a focus on: (1) patients' Despite engagement with the issue of medical tourism in the published literature, it is clear that there is profound paucity of theoretical and empirical understandings of this practice that can ultimately help us to understand the patient's experience. With empirical evidence lacking, authors have frequently drawn on media sources to substantiate their claims. We believe that the time is ripe for social and health scientists from various disciplinary, theoretical, and methodological perspectives to go beyond enduring speculations about patients' experiences of medical tourism. As a starting point, we have identified a number of pressing research direction above. Finally, we hope the identified knowledge gaps and research challenges, along with the scoping review findings, illustrate the exciting possibilities for how scholars can make significant contributions to what is known about the patient's experience of medical tourism.US: United StatesThe authors declare that they have no competing interests.VAC led the identification of themes and writing of this manuscript. All authors contributed to the design of the scoping review, reviewing sources, and assisting with data management and interpretation. All authors provided feedback throughout the drafting of this article and have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/10/266/prepub


Childhood asthma is common in Cape Town, a province of South Africa, but is underdiagnosed by general practitioners. Medications are often prescribed inappropriately, and care is episodic. The objective of this study is to assess the impact of educational outreach to general practitioners on asthma symptoms of children in their practice.This is a cluster randomised trial with general practices as the unit of intervention, randomisation, and analysis. The setting is Mitchells Plain , a dormitory town near Cape Town. Solo general practitioners, without nurse support, operate from storefront practices. Caregiver-reported symptom data were collected for 318 eligible children (2 to 17 years) with moderate to severe asthma, who were attending general practitioners in Mitchells Plain. One year post-intervention follow-up data were collected for 271 (85%) of these children in all 43 practices.Practices randomised to intervention (21) received two 30-minute educational outreach visits by a trained pharmacist who left materials describing key interventions to improve asthma care. Intervention and control practices received the national childhood asthma guideline. Asthma severity was measured in a parent-completed survey administered through schools using a symptom frequency and severity scale. We compared intervention and control group children on the change in score from pre-to one-year post-intervention.Symptom scores declined an additional 0.84 points in the intervention vs. control group . For every 12 children with asthma exposed to a doctor allocated to the intervention, one extra child will have substantially reduced symptoms.Educational outreach was accepted by general practitioners and was effective. It could be applied to other health care quality problems in this setting. Asthma is common among children in Cape Town, South Africa, and is of great concern to the relatively poor communities where rates are highest, and where understanding of the disease and treatment adherence are poor ,2. AlthoIn Cape Town, tax-funded public health care provides for the uninsured through a network of ambulatory care centres where nurses triage and doctors diagnose, prescribe, or refer to specialist care at public hospitals . This syMitchells Plain is a dormitory town 30 km from Cape Town with a population of 300,000 people. Racially classified in the apartheid era as 'coloured', the residents suffered severe discrimination, with resulting social problems including high unemployment, overcrowded accommodation, poverty, alcohol and drug abuse, and criminal and family violence.Private healthcare in Mitchells Plain is usually provided by solo doctors without nurse support operating from storefront practices in the community Figure . There iEducational outreach (or academic detailing)  involvesThe design was a cluster randomised controlled trial with the general practices as the unit of randomisation, intervention, and analysis. The study conforms to the Consort group recommendations for such trials  and was A list of practices was composed in 1998, after identifying practitioners named in the baseline data from the medical register and telephone directory. Practices within the study area were numbered and randomised to two groups using a computer-generated list of random numbers.We included all general practitioners, both practice principals and their hired doctors, working in private practice in Mitchells Plain. There were no multipartner practices. We included all schoolchildren up to age 17 living in the study area and their preschool siblings two years old or older with moderate to severe asthma. We determined their eligibility based on their answers to parent self-administered questionnaires and confirmatory face-to-face interviews conducted three months later.The intervention was a tailored, multifaceted educational outreach intervention based on qualitative and survey research that identified barriers to the appropriate medical diagnosis and treatment of children with asthma in a similar nearby community Table  12]. It. It12]. The intervention contained eight key messages to convey to practitioners. We included only messages related to clinical behaviours that we believed to be largely under the control of the practitioner; in other words, free of external constraints and thus amenable to change by the practitioner Table .The intervention was delivered during 1998 to individual practitioners by a pharmacist trained in the methods of academic detailing. A first visit took 30 minutes with a repeat visit of similar duration conducted three months later. At the first visit, the pharmacist used a visual aid, a set of printed glossy materials similar to those used by pharmaceutical company representatives, structured as a plastic laminated desk blotter, on which the key messages were outlined Figure . The bloThe principal outcome for the trial was the change in an individual child's asthma symptom score reported by the parent or guardian before and after the intervention. The South African Consensus guidelines use a severity grading of childhood asthma based on frequency of attacks of tight chest, nocturnal coughing, and nocturnal waking, hospital admissions, and peak flow rate. The three attack frequency questions were amenable for use in a brief interview, and were weighted by zero to three points, according to frequency of episodes in the previous 12 months, using weights developed in a previous study in this community , where oThe score obtained for these three frequency questions was added to give a total score. The maximum score attainable was nine points and the minimum score attainable was zero points. Children with the highest pre-intervention symptom scores were included until the desired sample size for the trial was obtained. In contrast with the specific symptom questions in the score, we also asked parents a number of questions designed to measure their perception of the child's asthma severity and the effect of asthma on participation in usual activities such as school . Self administered questionnaires and interviews were completed in the respondents chosen language. Interviewers and parents were blinded as to the allocation of practitioners.The process was designed to obtain a group of children whose parents consistently reported their usual source of care as one or more participating private practitioners, and whose pre-intervention symptoms were compatible with moderate to severe asthma. We thus excluded at screening children whose parents reported no usual private general practitioner, or whose home address was outside Mitchells Plain. At the baseline face-to-face interview, we also excluded children whose parents reported that their child's usual family practitioner was outside the study area, and at follow-up face-to-face interview, we further excluded children whose parents identified as their practitioner a doctor who was not on our list of randomised practitioners.We wished to detect a clinically meaningful improvement, 0.5 standard deviations, in the symptom score between intervention and control groups . We assua priori, were the baseline score and the number of visits to the usual practitioner during the study period. We conducted the adjusted analysis using Proc GENMOD in SAS.Data were collected on paper and entered into a computer. They were managed and analysed using SAS . We report univariate descriptions, cross-tabulations with chi-squares, and, for adjusted analysis of the principal outcome, the asthma symptom score, we report a linear regression analysis on the change in asthma symptom score from pre-to post-intervention evaluation. The clustered design was accommodated by fitting the generalised estimating equation version of the linear regression model with an exchangeable working correlation model. To check the findings of the linear model on the change scores, an ordinal logistic regression analysis using the proportional odds model was carried out on the post intervention score . Since tPermission to contact parents of schoolchildren to complete a survey was obtained from the Department of Education for the province, and then, during an information meeting at each of the primary schools in the study area, permission was sought from, and granted by, each school principal and class teacher.Plain language explanations of the purpose of the study and its voluntary nature were included with the self-administered questionnaire sent to parents. Return of the questionnaire indicated consent to use the data. During home visits, the study was again explained and confirmatory verbal consent was obtained.Intervention group practitioners were contacted to obtain an appointment for the academic detailing visit. At the beginning of the visit, some well-known problems of asthma care and the academic detailing intervention were outlined, and the doctor's participation in an evaluation of the intervention was invited. No monetary reward was offered. Control group practices received a hand-delivered copy of the then current South African childhood asthma guideline. Because practitioner records were not used for identification or follow-up of children with asthma, no permission was required from practitioners for this element of the study.Ethical approval for the study was granted by the Medical Research Council of South Africa Ethics Committee.We identified 43 practices at the start of the study, 21 of which were randomised to intervention, and 22 to the control group  ranged from 1 to 17 years of age , with an equal number of boys and girls. Children in the control group n = 145) also ranged from 1 to 17 years of age , with 70 boys and 75 girls  and the control group (3.24) Table . The decAt baseline, the mean asthma symptom score was higher in the intervention group, suggesting a slightly more severe distribution of disease in that group Table . AdjustiTo investigate the effect on the principal outcome measure of the number of visits to the specified physician, this factor was added to the model as a linear effect. The estimated intervention effect Table  was closThere were no significant differences between the intervention and control group respondents in their subjective assessment of their children's overall asthma severity in comparison with the previous year, nor in their ability to undertake normal school activities Table .This study appears to be the first to show improvements in childhood asthma symptoms in a lower or middle income country following educational outreach. The measure of outcome has not been formally validated. However, it is a simple set of symptoms that are a commonly occurring feature of the disease, well known to parents, and thus the measure has high face validity. In addition, when used in a randomised trial as here, error and poor recall would bias towards a null effect. The substantial effect on symptoms which we found is therefore likely to be an underestimate of the true effect of this intervention.The improvement in asthma symptoms is unlikely to be explained by bias, because the intervention and control patients and practitioners were comparable at outset, the analysis was by intention to treat, there was no loss to follow-up among practices, and little differential loss to follow-up of patients.Identification of patients through a school-based survey rather than practice records protected the study against possible bias from differences in recordkeeping standards and reduced logistical difficulties. Collecting data from schools also minimised the impact of the trial on physicians' awareness and possible changes in behaviour due to that awareness. It also enabled us to measure the effect of the intervention on unselected practitioners rather than on volunteers. The results are therefore likely to be applicable and useful in similar settings.Only one practitioner refused the outreach visits, and his patients were analysed in the allocated group, and the result is thus a real world finding. Academic detailing was a welcome intervention in practice settings such as these, as demonstrated in accompanying qualitative research reported elsewhere . It is lThe decline in reported symptoms over one year in both the intervention and control groups was likely due to aging of the children in the study, and may also be due to regression to the mean. The intervention reduced asthma symptoms even further in the intervention group (0.84). For a cut point of six or above on the nine point symptom scale that was used, one additional child in the intervention practices benefited for every 12 children cared for in those practicesIn contrast with the improvement in asthma symptoms, there were no improvements in well-being or burden of the disease, as measured by global questions. This might be due to the high threshold of response to illness in a relatively poor community, the insensitivity of global questions in comparison to the very specific and memorable events tapped by the symptom severity questions in the scale, or the lack of power for the global questions, which were dichotomous.Few other studies of educational outreach have measured health outcomes, few have been undertaken in private practice in a poor urban community, and none have measured outcomes using a school-based survey rather than medical records or administrative databases. These pragmatic characteristics of this trial increase its relevance in this setting, widen its applicability, and demonstrate that it is possible to conduct rigorous evaluations of behaviour change interventions in low and middle income settings.Alongside this study we explored physicians' perceptions of the outreach visits through qualitative means, described in reports available elsewhere . AlthougThe setting in which the intervention was applied was a difficult one with individual storefront practices, where physicians have very little organisational support. The main source of treatment information in such practices is likely to be from drug company representatives. Using the familiar drug company detailing model, we were able to meet with practitioners and tailor the message to their needs and conceptions of the problem.This intervention appeared affordable for a low-to middle-income country like South Africa, and would add about 0.01% to the annual public sector healthcare budget for each condition at which outreach was aimed, if used nationwide once per physician per annum. We also have successfully used an educational outreach approach to nurse clinicians in even more impoverished and rural parts of South Africa . PolicymME is co-editor in chief of Implementation Science, JG is a member of the editorial board. All editorial decisions on this paper were made independently by co-editor in chief, Brian Mittman, not an author. All other authors have nothing to declare.MZ conceived the project, led the design of the interventions, the trial, the barrier and pilot studies, contributed to analysis, and wrote the drafts. All other authors contributed to editing and approval of the final version, and in addition, AB contributed to design of the interventions and qualitative evaluations, conducted the intervention and led the fieldwork; CL led all statistical aspects of design and analysis, while GS, RE, AO, SP, MS, ME, and JG contributed to conception of the project and the intervention, supported design of the trial, and contributed to analysis.CONSORT checklist. List of items to include when reporting a randomized trial.Click here for fileSurvey instrument. Questions on asthma symptomatology and demography of included children.Click here for file


Many new initiatives for population health improvement feature partnerships of leaders and organizations across multiple sectors of society. The purpose of this article is to review 1) the rationale for such partnerships as an important, if not essential, tool for population health improvement; 2) key organizational and contextual factors that appear to be associated with effective multisector partnerships; and 3) the limited evidence regarding the effect of such partnerships on population health outcomes. We conclude that systems thinking — accounting for the collective effect of many actors and actions — is essential to organizing and sustaining efforts to improve population health, and to evaluating them. More research is needed to understand how and why multisector partnerships are formed and sustained and the conditions under which multisector partnerships are necessary or more effective than other strategies for population health improvement. Research on and evaluation of multisector partnerships also need to incorporate more standard measures of partnership contexts, characteristics, and strategies and adopt longitudinal and prospective designs to accelerate social learning in this area. Finally, studies of multisector partnerships must be alert to the value of such initiatives to individuals and communities apart from any direct and measurable impact on population health. In response to the call of the Institute of Medicine for multisector partnerships , many neDuring the past 3 decades, efforts to improve population-wide health outcomes have moved toward community organizing and collaboration. Community organizing refers to the unit of analysis and action, shifting the focus from individuals to systems, rules, social norms, or laws to affect health behaviors and outcomes . This ecCollaboration refers to the process of system change, shifting the focus from the responsibilities and effectiveness of individual institutions to their relationships and collective effect on population health. In particular, efforts have increased to involve many sectors of a community in pursuit of better health outcomes and the economic and social benefits thought to be associated with such outcomes. The rationale behind multisector partnerships is that, because no single organization or sector has full control over the determinants of population health, effective solutions require interorganizational coordination and collaboration . By poolResearchers have conceptualized partnerships for health improvement differently. Three dominant models of partnerships for health improvement have been described . In the In response to the mixed results of approaches based on the third model, some argue it is necessary to reconceptualize partnerships for health improvement . AccordiRecent work on social networking approaches to collaboration examines the importance of looking at the effect of a particular intervention rather than measuring the changes in a system over time. In network approaches, leaders focus not only on management challenges and opportunities at an organizational level but also on how to mobilize resources more broadly for the greatest social impact .Drawing from these approaches, a fourth conceptualization of multisector partnership seems to emerge. This model focuses not only on the relationships among organizations in the partnership but also on the partnership's relationship to the context of the place it is trying to change. In some ways, this model is a continuation of the focus on neighborhood-based and community initiatives. However, it adds a new emphasis on considering the characteristics of context, including the timing of the intervention and past events, particularly earlier interventions that may have created networks. From this perspective, partnerships work to build capacity over time and consider the impact on the context itself as the primary outcome.Extensive research has identified the qualities perceived as contributing to strong multisector partnerships in health and other issue areas. This section summarizes some of the lessons learned about the most important dimensions of partnerships.Partnership resources include the money, skills and expertise, information, and connections that a partnership has to draw on . AlthougMultisector partnerships bring together groups with disparate interests and roles. One of the most universally recognized needs is a common vision for the partnership's projects, goals, and outcomes .Partnerships without clear goals that rely on broad agendas may become distracted by emerging crises and side issues. Another risk is to become so narrowly focused that the partnership ignores important community and contextual issues. A related concern is ownership of the vision for the project. Researchers emphasize that communities that are being served by the partnership must contribute to the vision for the project, creating a sense of ownership and empowerment ,14.Effective leadership is one of the most studied characteristics of effective partnerships ,15-17. LResearch demonstrates the importance of building leadership at many levels. Along with leaders who possess expertise and experience in the issue area, collaborations need sponsors who can provide resources to the enterprise and champions who possess the necessary process-oriented skills to keep the collaboration going. Champions are particularly important because a diverse organizational partnership may lack a clear-cut strategy that can be centrally developed and easily enforced .The effectiveness of partnerships depends on their organizational structure and capacity. As with leadership, no one form can serve all partnerships equally well. Effective partnerships appear to share several features, however, including clear structure, adequate staffing, sufficient core resources, and transparent decision-making processes ,13,16.A core test of organizational structure and process is the ability of a partnership to deal with conflict. In multisector collaborations, conflict is common and emerges from the marriage of different organizational cultures with varied views about planning, strategies, and tactics. Collaborations that have continual trust-building activities are more likely to manage potential conflict. Conflicts exist not only at an individual level but also at the systemic level. Consequently, collaborations are more likely to succeed when they build in resources and tactics for dealing with power imbalances . To achiSelection of the right partners is necessary for success. Partnerships aimed at community health improvement should include a broad array of partner organization types . MembersThere are potential risks, however, in forming new collaborations. Recruitment of members presents a tradeoff between representativeness and effectiveness. Up to a point, expanding representation can increase legitimacy and attract more resources for an initiative. But coalition size and diversity may make it harder to reach decisions and develop and implement new programs .Although newly constituted partnerships may have the advantage of not being obligated to any particular community group, they may lack credibility and power. Partnerships must therefore strategically align themselves with established groups . Bryson Forty coalition leaders named commitment to the cause as the main element of coalition success. Additional factors named were commitment to coalition unity, breadth of representation, continuing contribution of resources, and previous history of working relationships .In addition to the desired structural characteristics of partnerships, the quality of the relationship distinguishes effective partnerships from ineffective ones. This sense of collaboration or group cohesion is complex and difficult to operationalize. Nonetheless, strong collaborative working relationships are often credited with allowing multisector partnerships to provide integrated service delivery ,16. GoodThe influence of community characteristics on the success of collaborations is a subject of growing interest. Some communities may have more readiness or be more conducive to the work of the partnership ,10. FeinCommunities each come with their own public and organizational policy barriers to partnerships. Financial barriers may include short-term or limited external funding, lack of funding for administration and management, and categorical program requirements. Other barriers may include performance standards or current benefit requirements that discourage key leaders or organizations from participating .Although external factors affect the success of collaborations, the research on community coalitions suggests that the collaboration's response to those factors is more important to the development of the collaboration. Members of community coalitions routinely name  political, economic, and community conditions as important in coalition development. However, they identify additional factors as more important, such as choosing a relevant issue, having the right timing, and choosing an appropriate social target .Despite a common belief that multisector collaboration can improve population health, researchers seldom study the effect of such collaboration on population health outcomes. Evaluating the effect of multisector partnerships on population health outcomes is difficult. Some of the most-cited challenges are the short study period of evaluations, limited use of evidence-based logic models and theories of action to guide interventions, the difficulty of measuring the degree of individual exposure to interventions, and multiple or broad population indicators .Researchers fail to agree on what factors are most closely linked to improved population health outcomes. Often these factors have been drawn from a broad review of literature from multiple disciplines, each defining efficacy differently . Even reIn a review of hundreds of collaborations, Roussos and Fawcett  could idAnother literature review  yielded not necessary to improve health outcomes or reduce health disparities.Kreuter and Lezin  observe General lessons are available: first, systems thinking is essential to organizing and sustaining efforts to improve population health, and to assessing their impact. The outcomes of partnership approaches depend on the social, economic, and political context of the community in which partnerships are formed and operate. Only by studying the varying contexts can researchers discern whether any form of partnership is sufficient for population health improvement.Second, characteristics of partnerships — goals, sponsorship, membership, resources, leadership — do appear to matter, but this has been established primarily through studies based on perceptions of participants rather than objective measures of outcomes. Therefore, more research is needed on multisector partnership outcomes using longitudinal and prospective designs that include measurement of activities, social network development, and types of organizations involved and resources engaged. To aid this area of inquiry, better and more widely adopted measures of structure, process, and outcomes are needed to link partnership formation to community-wide impact. One step toward building a stronger evidence base of what works would be the adoption of common models or frameworks for defining different forms of public health partnerships — for example, the typology offered by Mays . StandarThird, multisector partnerships almost certainly offer some value to individuals and communities apart from any direct and measurable effect on population health. The shared effort and communication that result from a health initiative may highlight problems, shift resources, or raise expectations for participation and performance in other areas of community life. Studies of multisector health partnerships should be alert to such catalytic changes and spillover effects as researchers pursue a clearer view of the connections between partnerships and population health improvement.


Manual searches of other relevant journals and reference lists of primary articles.Qualitative studies (n = 18) on women's experiences of abortion were identified. Analysis of the results of studies reviewed revealed three main themes: experiential factors that promote or inhibit the choice to seek TOP; experiences of TOP; and experiential aspects of the environment in which TOP takes place.Women's choices about TOP are mainly pragmatic ones that are related to negotiating finite personal and family and emotional resources. Women who are well informed and supported in their choices experience good psychosocial outcomes from TOP. Home TOP using mifepristone appears attractive to women who are concerned about professionals' negative attitudes and lack of privacy in formal healthcare settings but also leads to concerns about management and safety. Although abortion or termination of pregnancy (TOP) by clinical means is politically contentious in some countries (notably the US), in most developed countries it has become a normalized  componenexperiences of the two methods. This paper goes some way towards filling that gap by providing a narrative review of qualitative studies of women's experiences of TOP and their perspectives on surgical or medical methods. Given the importance of this topic to policy and clinical practice around reproductive health, this is a surprisingly small body of literature, but it is highly heterogeneous and contextually specific.The emphasis on establishing clinical and cost effectiveness of medical versus surgical TOP means that less attention has been paid to women's An initial scoping exercise established that the qualitative research literature was too heterogeneous to permit a systematic review of qualitative studies along the lines proposed by Dixon-Woods , or a thReproductive Health Matters; Health Care for Women International; Contraception) and reference lists of primary articles found from initial searches were also conducted. These searches revealed four comparative qualitative studies of surgical versus medical TOP [The review focused on the period 1998–2007 because it was during this period that medical TOP has become established in practice. The primary focus of the review is therefore on women's experiences of TOP, and this meant that other studies  were excluded. Studies included in the review were identified by keyword searches of Medline, Psychinfo, CINAHL, ISI, and IBSS databases. Keywords searched included 'abortion', 'terminat*, pregnan*', 'unplanned pregnancy', in combination with 'qualitative study', semi-structured, ethnograph* experiences', of which 'abortion experiences' yielded the most relevant material. Manual searches of other relevant journals  and snowballing ,31,32 anThe review identified two groups of qualitative studies on TOP.medical TOP,  Studies that focused on experiences of pristone , and twopristone ,17. A fupristone .general experiences of TOP  Studies that explored choice to seek TOP; experiences of TOP; and experiential aspects of the environment in which TOP takes place.Analysis of the results of studies included in this paper revealed three main themes: experiential factors that promote or inhibit the The watchword of campaigners for abortion services has been that it is the woman's right to freely choose between abortion and pregnancy . StudiesWhatever women's circumstances, studies in this review suggest that the decision to seek TOP usually precedes any encounter with heath care professionals ,28,29. Hchoice of TOP provider is framed, or even what choices are available. One study of young women in the UK [The range of services available also affects the choices of women. However, papers identified for review provided little about how the n the UK  found thn the UK -24. For n the UK .In the UK, expectations of better personal treatment and confidentiality were also reasons why some women chose private or voluntary sector clinics over National Health Service (NHS) clinics, although cost is an issue . Those wchoice of method is dependent not only on service availability but on medico-legal considerations such as the gestational age. Once again, data on this topic are very limited. Pragmatic reasons such as effectiveness and the side effects were found to over-ride women's moral and political considerations in one US study [Finally, the US study . PreviouUS study ,17. The US study .et al [Studies that concentrated on women's experiences of the TOP procedure prefaced their findings with an account of the specific medical regimens in place at the time of the study. The US studies focused on women's perceptions of medical abortion as a new procedure, and often compared this with surgical TOP. In this context, women identified medical abortion as a way to avoid surgery, and anaesthesia and that permitted them privacy, autonomy and a greater sense of control ,17-19. Set al , in partet al .Complex emotional experiences appear to be integral to TOP. These include regret and guilt ,22, distmurder, leading some women to think that they 'killed a baby', but also realising 'it wasn't really a child' [Such perceptions are mediated by the moral context within which the women are located. In Indonesia, for example, women's perception of the fetus is influenced by the Islamic view that ensoulment takes place at 120 days of pregnancy . In the a child' . In a sta child' , reservaa child' ,30,32. Ia child' . Some woet al [Feminist researchers provide insights into the interaction of TOP with notions of reproductive independence. A study  on the let al  showed tOther studies highlight the isolation of women undergoing TOP and their concerns to conceal it from others ,26. In sThe role of service providers is examined in most of the studies and British studies have focused especially on health services access and quality ,28,29. TWomen's experiences of patient care during an abortion are also affected by the method of termination. In US trials on medical TOP, women relied on health professionals to assure them about the safety of the new procedure and to determine if the termination had been successful . Women nIn some contexts, the attitudes of health providers to abortion were relative to the marital status of the women . In IndoStudies that included primary care primary care professionals suggested that these were perceived as less sympathetic and supportive than professionals working in abortion services. The latter were perceived to be more caring and less judgemental ,28. ThisCounselling is referred to in different ways in the studies but most particularly as counselling prior to the TOP to discuss the different methods, their benefits, what to expect, compliance and follow-up  and in rSome studies also investigated women's experiences of medical TOP at home rather than at a clinical facility -18,22. IQualitative studies published on TOP within the time frame of this review have been limited in scope and detail. In this article, we have identified two main groups of studies; those that specifically address the issue of medical abortion, and those that explore the experiences of TOP more generally. Studies reviewed in this paper were influenced by a range of contextual factors such as political, ethical, social and legislative environments as well as health, economic and welfare systems. Research from the US, UK and Sweden dominated the literature, but these three countries have very different patterns of service provision. This review leads to four main conclusions.(i) Women's choices about whether, where, and how, TOP should be undertaken are mainly pragmatic ones that are related to negotiating finite household and psychosocial resources.(ii) Rapid access to services characterised by supportive non-judgemental staff who delegate medical control over the process to women appear to characterise positive responses to medical TOP.(iii) Home TOP using mifepristone appears attractive to women who are concerned about professionals' negative attitudes and lack of privacy in formal healthcare settings but also leads to concerns about management and safety.(iv) Women who are well informed and supported in their choices experience good psychosocial outcomes from TOP.These are broad conclusions derived from a very limited corpus of qualitative research. A recent review  of psychThe authors declare that they have no competing interests.CRM conducted an initial literature scoping exercise. MLSL conducted the literature searches, collected and collated articles, and drafted this paper. SCR and CRM commented in detail on drafts and contributed to the final version of the manuscript.The pre-publication history for this paper can be accessed here: