Different models exist to provide HIV/STI services for most-at-risk populations (MARP). Along the Tete traffic corridor in Mozambique, linking Malawi and Zimbabwe, a night clinic opening between 4 and 10 PM was established targeting female sex workers (FSW) and long-distance truck drivers (LDD). The clinic offers free individual education and counselling, condoms, STI care, HIV testing, contraceptive services and outreach peer education. To evaluate this clinic model, we assessed relevance, service utilisation, efficiency and sustainability.In 2007-2009, mapping and enumeration of FSW and LDD was conducted; 28 key informants were interviewed; 6 focus group discussions (FGD) were held with FSW from Mozambique and Zimbabwe, and LDD from Mozambique and Malawi. Clinic outputs and costs were analysed.An estimated 4,415 FSW work in the area, or 9% of women aged 15-49, and on average 66 trucks stay overnight near the clinic. Currently on average, 475 clients/month visit the clinic . The average clinic running cost is US$ 1408/month, mostly for human resources. All informants endorsed this clinic concept and the need to expand the services. FGD participants reported high satisfaction with the services and mentioned good reception by the health staff, short waiting times, proximity and free services as most important. Participants were in favour of expanding the range of services, the geographical coverage and the opening times.Size of the target population, satisfaction of clients and endorsement by health policy makers justify maintaining a separate clinic for MARP. Cost-effectiveness may be enhanced by broadening the range of SRHR-HIV/AIDS services, adapting opening times, expanding geographical coverage and targeting additional MARP. Long-term sustainability remains challenging and requires private-public partnerships or continued project-based funding. Female sex workers (FSW) are a hard-to-reach, socially and economically vulnerable population with inadequate access to health, social and legal services. They are at increased risk for HIV, sexually transmitted infections (STI) and other sexual and reproductive health and rights problems (SRHR) -5. In SuDifferent models exist to provide targeted HIV/STI services. In large African towns, a model of FSW-specific clinics is often implemented -13. ThisIn 2001, in Northern Mozambique, along the 'Tete corridor' connecting Zimbabwe with Malawi, a 'night clinic' was established specifically targeting FSW and LDD. The clinic is located near a major truck stop, 20 km from the provincial capital Tete, at the edge of Moatize town, and opens at a time considered convenient for the target populations (4-10 PM). Initially the clinic offered STI care and information, education and communication (IEC) on HIV/STI. In a subsequent phase, services were expanded to include contraceptive services and voluntary testing and counselling for HIV and syphilis. A group of 20 peer educators were trained in behaviour change communication and condom distribution. All services are free of charge. The clinic currently operates with health staff and medical supplies from the public sector, with financial and technical support from the International Centre for Reproductive Health (ICRH) in the context of a project funded by the Flemish International Cooperation Agency.In 2007, concerns were raised about the long-term future of the clinic and it was agreed to quantify the size of the target populations and assess (1) if the model of a separate clinic targeting MARP remained relevant, (2) if the organisation of the services was appropriate to the needs of the target groups, (3) if the services were delivered at a reasonable cost, (4) if there was a demand for additional SRHR services, and (5) if the model was sustainable on the long term.A mapping and enumeration of sex workers in the two major urban centres near the clinic, Tete and Moatize, was conducted in 2008. First a mapping was done of all establishments and places where FSW recruit clients, and all establishment managers were interviewed using a structured questionnaire. Topics covered included characteristics of FSW and clients at the establishment, time of peak sex work activity and characteristics of sex work. Based on this information, the day of the month and the hours of the day of peak FSW activity were identified and during that period the number of FSW was enumerated. The two towns were divided in 11 areas, where, simultaneously, pairs of peer educators counted FSW actively recruiting clients, identified through predefined criteria of behaviour and appearance. Data were analysed using MS-Excel. In addition, an enumeration was conducted in 2007-2008 of the number of trucks that stayed overnight at the nearby truck stop.Eight key informants, from the Provincial and District health authorities, the Provincial AIDS Council, non-governmental organisations and a mining company, were individually face-to-face interviewed using semi-structured questionnaires. The 3 clinic staff and 17 peer educators were interviewed in two separate groups. Topics covered included the type of relationship with the clinic, opinions about the performance of the clinic , suggestions for improvement, opportunities for collaboration and suggestions for ensuring long-term sustainability. Notes were taken by the interviewer and transcribed the same day.To obtain client perspectives, six focus group discussions (FGDs) were held at the beginning of 2008 using a discussion guide, one with Mozambican FSW (n = 8), one with Zimbabwean FSW (n = 8), two with Mozambican LDD (n = 8 and 10) and two with Malawian LDD (n = 7 and 7). The project peer-educators recruited known FSW from bars and hotels near the night clinic. LDD were recruited from the nearby truck stop and through two major transport companies. Discussions were held at the clinic or in a private room at a restaurant. All participants gave verbal informed consent. Topics discussed included experiences with the clinic, a comparison of the clinic to other health services and suggestions to improve the services. The discussions were guided by a trained moderator in the language chosen by the participants  and lasted approximately one hour. Notes were taken in Portuguese, which the moderator and note-taker together transcribed directly afterwards.Routinely collected information of the clinic between September 2004 and June 2009, including the number of clients, socio-demographic, behavioural and clinical characteristics, motivation for the visit, and operational project costs, was entered in MS-Excel and monthly averages were calculated.The study was conducted according to international ethical standards. The Mozambican ethical guidelines only require ethical clearance for studies that collect individual data from human subjects. All of the applied methods, including the focus group discussions, are not considered as such and no ethical clearance was needed.The results of the different data collection methods were triangulated to assess (1) relevance of the model, (2) service utilisation, (3) service delivery efficiency and (4) long-term sustainability.During the mapping, a total of 221 sites where FSW recruit clients were identified in the two towns, 218 establishments (bars or hotels) and 3 outdoor areas (streets). The periods of peak FSW activity were said to be the end and the beginning of the month, on Friday and Saturday nights, between 6 PM and midnight. The most important clients of FSW were said to be merchants, students, truck drivers and public servants.An enumeration of FSW between 7:30 and 9 PM on a Friday night at the beginning of the month in all establishments counted a total of 4,415 FSW active during that period, 1,158 in Moatize and 3,257 in Tete town. The estimated number of women aged 15-49 years in the two towns is 48,500 and the estimated ratio FSW/women aged 15-49 years is therefore 9.1%.Between 13 December 2007 and 4 January 2009, 19,210 trucks were counted staying overnight at the truck stop near the clinic, giving an average of 66 trucks per counted night. About half (54%) was of Malawian origin, 20% of Zimbabwean, 16% of Mozambican and 10% of other origin.All interviewed informants endorsed the concept of a separate SRHR clinic for MARP and the need to expand these services to other parts of the province. However, they all agreed that currently this type of services cannot be offered by the public health system, because the national health policies do not recognise separate health facilities for MARP.Both FSW and LDD participating in the FGD, of all nationalities, reported satisfaction with the night clinic and mentioned the good reception by the health staff, the prompt attendance, the proximity and the services free of charge as most important strengths of the clinic in comparison to other, formal and non-formal, health care providers.'In relation to the clinic's reputation, I think it is good. You know why? Because it is free and because of the staff that attends us. Each time I come here, they are always ready. I pass here often.'Malawian LDD: '... Nothing compares to this clinic. The information given is clear and simple while in the hospitals where I went it takes a long time, you spend money and sometimes you are rapidly dispatched because of the crowdedness and not adequately treated...'Zimbabwean FSW: '... the clinic is very well situated, it is near our depot, is easy to reach, and in little time, I like the attendance, and the services that are offered are excellent...'Mozambican LDD: Stigmatisation at the regular health services was in particular reported by Zimbabwean FSW.'...In other hospitals we are badly attended because we are Zimbabweans. They say they don't understand our language and that we are prostituting men who are their husbands. We have to undergo all sort of humiliation in addition to spending money...'Zimbabwean FSW: Negative feedback on the clinic's activities was given by a Zimbabwean FSW who reported a stigmatising attitude by the peer educators. An LDD participant suggested using male peer educators for LDD, because female peer educators might be perceived as FSW.'...Who I really don't like are the peer educators. They sometime mock us and say that the Zimbabweans came to steal our bread. Here it is the rule of survival. We are a lot. Sometimes there is not a lot of business and we argue over the same client...'Zimbabwean FSW: 'I propose to have male activities as well, for the counselling of truck drivers. Because these female activists, many of us we end up seducing them and so they make another profit.'Malawian LDD: Some FSW participants complained of security problems and violence against them.'Here in Moatize we are facing violence against sex workers. We need peer educators patrolling in the parking station of the truck drivers'Zimbabwean FSW: The average number of monthly clinic visits gradually increased from 206 in 2005 to 475 in 2009 Table . MonthlyDuring 2005-2006 several socio-demographic and behavioural characteristics were collected from clinic clients , medical equipment and furniture, utilities (water and electricity), security (three guards), over-time compensation for the nurses, training costs, educational materials and some condoms, and all peer educator costs. The project operational costs for the period 2004-2009 are summarised in Table The most important factor to increase the accessibility to the clinic was said to be a revision of the opening time of the clinic. Most focus groups agreed that the hours between 4-10 PM were not the most convenient and expressed a desire to open the clinic also during day time and during the weekend.'...The opening times should be from 12 to 18 h, because from 18 h onwards we start meeting our clients...'Mozambican FSW: '...I think the opening times should be changed to allow that we can be attended whenever we are passing through. Also during weekends....' '...I agree with my colleague, but I propose that the clinic is open from 10 h to 22 h...'Malawian LDD: '...Change [the opening times] because there are bandits here. From 18 h onwards we don't feel safe because of these bandits...others think wrongly that we come this way looking for men. Others think we have cell phones and money they can steal from us. One day we'll die because of cell phones. A better time is 14 h and closing at 18 h, or start at 7h30 and stop for example at 12 h, another starts and stops at 17 h'.Mozambican FSW: FGD participants were generally satisfied with the range of offered services. Some suggested offering treatment for common, not SRHR-related, illnesses, but others did not agree fearing overcrowding.'... I also would like that other illnesses would be treated at the clinic. For example malaria, because a lot of us get malaria in Beira where we sleep in the open and in the trucks and we are exposed to mosquitoes... That is important, yes. Malaria should be among the list of illnesses that are treated here.'Malawian LDD: 'I don't want to contradict that what my friend said [about treating malaria and diarrhoea], but I think it is better as it is, a treatment specifically for STI and HIV/AIDS tests. Because if the attendance would be expanded to other illnesses, we wouldn't have this luxury, and everyone would come to the clinic because it is free of charge, and there would be shortage of medicines, and the waiting time would be long, and we are the ones that would suffer.'Zimbabwean FSW: Some suggested providing more educational tools, such as films, others suggested offering ARV treatment to those who tested HIV positive.'We would also like that antiretrovirals would be distributed here.... [Now] It is necessary to go there [at the hospital], others already don't have the strength to go there, they are already very sick... When they do the test here and it is positive, they say to go to the hospital. Here they don't give antiretrovirals.'Mozambican FSW: Key informants reported that the public health system is currently contributing as much as possible within the national health policies. It provides the staff and all medical supplies, but it cannot finance the clinic and the peer education activities. A continued support by a non-governmental agency was said to be necessary. Funding can only be guaranteed through project-based funding or through private-public partnerships. The only two valid alternatives for long-term funding at the time of the assessment were (1) continued support through an externally funded project, or (2) development of a public-private partnership between the major mining companies and the Mozambican Government.The main question posed in the evaluation was if a separate clinic for the provision of HIV and other SRHR services for FSW and LDD is justified in the context of the Tete corridor. Many projects in similar contexts have opted to enhance access to existing health services instead of creating new services ,15,16. TFirstly, the size of the target population was much larger than anticipated and comparable to what is found in large urban areas. The ratio of FSW/women of reproductive age is higher than what is found in most settings in Sub-Saharan Africa .Secondly, all FGD participants strongly expressed their satisfaction with the clinic and preferred it above other health services. The arguments mentioned were that the clinic is much easier accessible, both because of its location and because of the limited waiting times, the reception is much better, confidentiality is guaranteed and the services are free. This coincides with the results of a cross-sectional survey conducted among FSW and LDD along the corridor in 2006 in which accessibility, confidentiality and free treatment were also the three most common reasons mentioned to prefer the night clinic above other health facilities . It is aA surprising finding was that the opening times, which were assumed to be appropriate for the target populations, did not appear to be so. Most FSW participating in the FGD expressed a desire to open the clinic earlier, and the later evening hours (after 8 PM) were said to be inappropriate for security reasons and because at that time they are already at work. Most LDD preferred opening hours during the day and weekends so that they can stop while passing the clinic.Thirdly, although the national health system never adopted the concept of clinics specifically targeting MARP, all interviewed health officials completely endorsed the model end expressed a desire to strengthen and expand it. This is further shown by the willingness to contribute as much as possible within the health system regulations, such as by providing the necessary drugs and medical supplies. The need of specific services for MARP is also increasingly recognised at central level in Mozambique  and it mThe frequentation of the clinic was initially rather low, but increased substantially the last two years mostly because of the increase in contraceptive services use. At the end of the assessment the number of daily visits to the clinic was about 21. To what extent the target populations are currently making use of the clinic is difficult to assess. Most FGD participants attended the clinic, but they were recruited from the immediate neighbourhood. The 2006 survey asked for treatment seeking behaviour for the last STI symptoms, but had not listed the night clinic among the options. Even so, 16% of FSW and 7% of LDD reported the night clinic under 'others' . The numThe cost of the clinic is relatively high. No figures were available on the start-up capital cost  and only the operational cost was analysed. Some of the operational cost, mainly the salaries of the health staff and the medical supplies, is borne by the national health system. This cost is not specific to the model of a stand alone clinic and is probably comparable to the cost of services for MARP integrated in existing health facilities. The additional operational cost caused by the stand alone model is borne by the project and comprises the cost of staff overtime, security, utilities and peer education. The total project cost varied from slightly under 1000 US$ per month at the beginning to around 1400 US$ per month currently, or about 4.5 US$ per client visit. This is high when taking into account Mozambique's limited resources for health . The long-term sustainability of the clinic remains therefore a challenge. The total cost can currently not be borne by the national health system, and external funding and support in the management of the services are necessary. A possible way out are long-term private-public partnerships with the mining companies that are currently initiating the exploitation of the coal mines in Moatize. Many of the companies' staff are at high risk for HIV and other STIs and therefore represent a potential target population for the clinic.The effect of the model in terms of number of HIV infections averted, unwanted pregnancies averted and DALY's gained is not known and it is not possible to appreciate the cost-effectiveness. However, HIV prevention among FSW is generally highly cost-effective -23 becauThe cost per visit can be reduced by enlarging the scale and expanding the services to other FSW and MARP at a greater distance and by better targeting FSW clients, including populations that appear to be important clients such as merchants and students. Attendance can be further increased by broadening the range of services offered. Although the clinic has expanded its services from purely STI care, IEC and condom distribution, to include testing and counselling and contraceptive services, it is still far from being a comprehensive SRHR clinic. When FGD participants were asked if they had any suggestions for extra services to be offered at the clinic, the highest need appeared to be access to treatment for general illnesses. Other participants were fully aware, however, that providing these services at the clinic would transform it into a general health clinic. Few participants requested extra SRHR services, such as for harm reduction or empowerment. This is probably because of the open way the question was asked and because FSW might not be aware of what services are possible. Indirectly, the need for extra services became clear, such as by the mentioning of the frequent occurrence of violence. A lack to access to antiretroviral treatment was also mentioned and there is a need to strengthen the prevention-care continuum.A substantial increase in the number of clients has the risk of compromising some of the factors that lead to client satisfaction, such as confidentiality or limited waiting times. The current average number of clients per hour is about 3.6 and there is little potential for further increase without expanding the opening hours or establishing outreach sites. A careful monitoring of client satisfaction is indicated.The current model for improving access to quality SRHR services for FSW and other MARP along the Tete corridor, Mozambique, is challenged by high incremental operational costs but remains a valid model overall. The performance can be enhanced by broadening the range of SRHR-HIV/AIDS services, adapting the opening times, expanding the geographical coverage, targeting additional MARP and further improve the quality of the services. Long-term sustainability can currently only be ensured by private-public partnerships or continued project-based funding.The authors declare that they have no competing interests.YL was the lead investigator during the performance assessment, developed the overall design of the assessment, the triangulation analysis and drafted the manuscript. He also developed and carried out the key informant interviews and the analysis of the clinic statistics and costs. DG greatly contributed to the overall design of the assessment and developed and carried out the focus group discussions and the mapping and enumeration. She helped to draft the manuscript. LC and CDML substantially contributed to the design and the preparation of the assessment and its different components. SL contributed to the design of the assessment, assisted in the triangulation analysis and helped to draft the manuscript. WD assisted with the analysis of the clinic statistics and costs and the revision of the manuscript. MT substantially contributed to draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/10/144/prepub


Almost every Western healthcare system is changing to make their services more centered around out-patient care. In particular, long-term or geriatric patients who have been discharged from the hospital often require home-based care and therapy. Therefore, several programs have been developed to continue the therapeutic process and manage the special needs of patients after discharge from hospital. Music therapy has also moved into this field of healthcare service by providing home-based music therapy (HBMT) programs. This article reviews and summarizes the settings and conditions of HBMT for the first time.The following databases were used to find articles on home-based music therapy: AMED, CAIRSS, EMBASE, MEDLINE, PsychINFO, and PSYNDEX. The search terms were "home-based music therapy" and "mobile music therapy". Included articles were analyzed with respect to participants as well as conditions and settings of HBMT. Furthermore, the date of publication, main outcomes, and the design and quality of the studies were investigated.A total of 20 international publications, 11 clinical studies and nine reports from practice, mainly from the United States (n = 8), were finally included in the qualitative synthesis. Six studies had a randomized controlled design and included a total of 507 patients. The vast majority of clients of HBMT are elderly patients living at home and people who need hospice and palliative care. Although settings were heterogeneous, music listening programs played a predominant role with the aim to reduce symptoms like depression and pain, or to improve quality of life and the relationship between patients and caregivers as primary endpoints.We were able to show that HBMT is an innovative service for future healthcare delivery. It fits with the changing healthcare system and its conditions but also meets the therapeutic needs of the increasing number of elderly and severely impaired people. Apart from music therapists, patients and their families HBMT is also interesting as a blueprint for home based care for other groups of caregivers. The use of music as a therapeutic option to support health dates back to ancient times. According to Bailey  some of Due to changes over the last few decades in almost every Western healthcare system towards more outpatient-centred healthcare programs, music therapy also moved into the field of primary care. The first MEDLINE-listed report on music therapy in a day care centre was already published by Pierce et al.  in 1964.Under these circumstances music therapy concepts are of fundamental interest for the continuity of care between in- and outpatient treatment. In particular, severely impaired or geriatric patients discharged from hospital risk losing therapeutic continuity because they are often not able to attend day care centres where music therapy is provided. Therefore, two major directions have been established within the field of music therapy. On the one hand, community music therapy programs focusing on the social and cultural relations of the client and establishing music therapy within his or her social context ; on the For the first time, this systematic overview focuses on settings and conditions of home-based music therapy programs. The main questions were whether and if so how HBMT can be part of an innovative and effective service for people who have to be treated at home.The following electronic databases were used to find articles on home-based music therapy: AMED, CAIRSS, EMBASE, MEDLINE, PsychINFO, and PSYNDEX. Databases were searched from their inception until 2010. The search terms were "home-based music therapy" and "mobile music therapy". In addition, an internet search was performed using Google Scholar. All articles found this way were fully read and their reference lists were checked for further relevant publications. To address a wide range of HBMT, there were no limitations in the initial search in terms of language, year, status, and form of publication. One of the inclusion criteria for all publications was that the music therapy services had to take place in the home of the clients. Therefore, all publications on other out-patient music therapy services were excluded. The complete search strategy together with the number of excluded studies is given in Figure If a study was found to be eligible, its methodological quality was assessed by two independent reviewers and recorded on a pre-determined checklist together with the basic trial data regarding participants, interventions, settings, outcomes, and study designs (PICOS) . This spAs the anticipated outcome was assumed to be a mixture of approaches, settings, legal aspects and outcomes relating to the perspectives of the patients, caregivers, and relatives and also due to the expectation of a quite heterogeneous data with respect to study design and used outcome measures, the authors decided against carrying out a meta-analysis of the results and decided to present the findings in a qualitative data synthesis.In total, the search identified 93 records after removing duplications. Of those, 61 did not sufficiently cover the field of home-based music therapy or were related to other therapeutic interventions. Thirty-two publications were found to be eligible for full text screening. However, another 15 articles had to be excluded due to reasons of setting while three additional articles, which had not been found by the database search, were retrieved from contacted authors , Germany (n = 4), Australia (n = 5), Austria n = 1), Japan (n = 1), and New Zealand (n = 1) were included in the qualitative synthesis  . AlthougThe musical repertoire offered to the patients contains classical music, new age music or easy listening music like folk or pop songs. Brandes et al.  developeOften the personal preferences of the individual clients are taken into account when choosing the music. According to McBride , this isSiedlecki  offered The combination of music listening programs with additional therapeutic techniques, like guided imagery, gentle massages, or movement, was quite common ,27. HansIn the field of active music therapy, singing and song writing are very common -26. PasiIn his study on music therapy with people with terminal cancer, Hilliard  describeThe information on duration of sessions shows a wide range: most authors reported that the average duration of a session can be between 20 to 60 minutes ,21,27,30The dates of publication of the articles range from late 1980 to 2010. Four publications from the early years mainly concentrate on conditions and the development of special HBMT-programs, whereas from 2003 onward there is an increasing interest in HBMT as a model of ambulatory service and it is closely related to changes in healthcare systems.Fields of applications of HBMT are similar in all studies: the majority of clients are the elderly living at home and people who need hospice and palliative care ,23,27-29In their study on the treatment of depression, Brandes et al.  argues tOnly the study from Pasiali  concentrNaturally, legal aspects of HBMT are very closely linked to the peculiarities of the healthcare system of the specific country. For that reason the reports from out of practice give relevant information on how a music therapist can establish ambulatory work -33. TherFor the first time, this review presents an overview of the field of home-based music therapy and describes settings and conditions represented by an international spectrum of articles.According to our findings, publications on HBMT cover two main aspects. The first is the search for new fields and forms of work for music therapists alongside with the changes in the health care systems. The second aspect is to meet the challenges of a society with an increasing number of chronically ill patients and people of old age and low mobility and to adapt health care services accordingly.The publications on HBMT show that receptive music therapy or singing songs with the clients play a predominant role in this working field. This might have organisational as well as economic reasons and takes into account the conditions of the ambulatory setting where the music therapist cannot carry too many instruments with him or her. Also the client as well as his or her relatives can listen to the music whenever it is wanted or needed. Accompaniment with a CD can be helpful when singing familiar or preferred songs. Nevertheless, further development and investigation of music therapy techniques and programs for the specific use in a home-based setting are important for the future of HBMT. Such can be found in publications from Austria, Australia, and the United States.The article by Horne-Thompson  might beThis aspect of HBMT as a kind of "systemic music therapy approach" is the subject of several studies. Thomas et al.  found thWhile spousal caregivers of people with dementia experience the care for their spouse over long periods of time as a significant burden with ever increasing physical, emotional, and social strain, in their ongoing study Baker et al.  concentrIn her pilot project, Muthesius  investigChiang  presumesAlthough we are confident that our literature search with an extensive internet search, hand-searching of grey literature and relevant conference proceedings and communication with experts in the field has identified all relevant papers on HBMT, there might still be unexploited sources of studies we might have missed. However, according to Mc Auley , grey liFinally, our internet search discovered a lot of HBMT initiatives in different countries which seem to be implemented in communal healthcare services. Unfortunately, a closer investigation did not reveal any publications about the outcomes of these services. As most of these services are integrated into local healthcare services for a longer time, successful outcomes can be assumed. In total, despite efforts to find all relevant publications, we can only give a fragmented view of the current state of play of HBMT without drawing a representative picture.The main questions for this systematic overview were whether HBMT can be part of an innovative and effective service for people who have to be treated at home and, if this is possible, how could it be implemented. It was of particular interest to identify the types of clients and conditions that can be addressed by HBMT and to understand which specialized MT-approaches and settings are needed for a home-based service.As a result of this review, there are only a few music therapy initiatives in the field of HBMT so far and quite a small number of clinical research publications in this area. Nevertheless, we were able to detect distinct fields of application for HBMT and special techniques for home-based services. The growing interest in HBMT in the last 10 years may indicate the potential of this service and refer to several advantages of HBMT as a future service in healthcare systems. HBMT is interesting for music therapists as well as for special groups of patients and their families and caregivers. This goes alongside the changing healthcare systems and its changing conditions but also it meets therapeutic challenges and needs of an ageing society with an increasing number of elderly and severely impaired people ,39.The possibility of integrating spouses, family members, or caregivers in HBMT and instructing them in selected music therapy techniques is an interesting aspect of future HBMT-services in view of lasting and economical aspects. It should be investigated in further studies. We would like to encourage researchers and music therapists to make distinct differentiations of approaches with clear research-based concepts for special groups of patients and to publish their results.In a more global scope of public health, HBMT could serve as a blueprint for other researchers in the expanding field of home-based care services. Knowing more about the problems and challenges before implementing home-based care services may help to reduce the efforts in structural planning and to improve the quality of psychosocial support. This is not only limited to related interventions like art therapy, but also may hold true for other kinds of individualized mind-body therapies applied to an ever-growing amount of patients who are unable to leave their homes.The authors declare that they have no competing interests.WS and TO both developed the research design for the review. WS was responsible for the literature research and TO screened the grey literature and contacted the corresponding authors. WS was mainly responsible for the data extraction, while TO cross-checked the results. Both WS and TO carried out the qualitative analysis, discussed the results, and wrote the paper.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/10/291/prepub


There is variation in the decisions made by telephone assessment nurses using computerised decision support software (CDSS). Variation in nurses' attitudes to risk has been identified as a possible explanatory factor. This study was undertaken to explore the effect of nurses' attitudes to risk on the decisions they make when using CDSS. The setting was NHS 24 which is a nationwide telephone assessment service in Scotland in which nurses assess health problems, mainly on behalf of out-of-hours general practice, and triage calls to self care, a service at a later date, or immediate contact with a service.All NHS 24 nurses were asked to complete a questionnaire about their background and attitudes to risk. Routine data on the decisions made by these nurses was obtained for a six month period in 2005. Multilevel modelling was used to measure the effect of nurses' risk attitudes on the proportion of calls they sent to self care rather than to services.The response rate to the questionnaire was 57% (265/464). 231,112 calls were matched to 211 of these nurses. 16%  of calls were sent to self care, varying three fold between the top and bottom deciles of nurses. Fifteen risk attitude variables were tested, including items on attitudes to risk in clinical decision-making. Attitudes to risk varied greatly between nurses, for example 27% (71/262) of nurses strongly agreed that an NHS 24 nurse "must not take any risks with physical illness" while 17% (45/262) disagreed. After case-mix adjustment, there was some evidence that nurses' attitudes to risk affected decisions but this was inconsistent and unconvincing.Much of the variation in decision-making by nurses using CDSS remained unexplained. There was no convincing evidence that nurses' attitudes to risk affected the decisions made. This may have been due to the limitations of the instrument used to measure risk attitude. Variation in decision-making is apparent amongst health professionals in a range of health care settings. In the United Kingdom (UK) there is wide variation in referral to secondary care at general practice and practitioner level , with twComputerised decision support systems (CDSS) are sometimes used by health professionals with the aim of supporting safety and consistency in their clinical decision-making. In the United Kingdom CDSS is routinely used in NHS Direct in England and Wales, and NHS 24 in Scotland, both of which offer 24-hour national telephone clinical assessment by nurses. One might expect there to be less variation in clinical decision-making between nurses in these services because of the use made of CDSS. However, protocols and computer programmes do not necessarily remove variability in health care ,9, and iAttempts have been made to explain variation in decision-making when CDSS is used. The type of software, and the length of nursing experience of individuals using the software, explains some of the variation in decision-making . Within In light of this, the aims of this study were to assess nurse attitudes to risk in telephone clinical assessment using CDSS, and to examine how far measured differences in attitudes between nurses explained the variation in decisions made. The study was undertaken in NHS 24. As well as offering a 24-hour service, NHS 24 is the frontline service for all out of hours general practice services and therefore a large proportion of calls to it are typically made in the evenings or at weekends. Nurse advisors use CDSS to clinically assess and triage callers and can advise them to self-care, to contact their general practitioner or out-of-hours service immediately or later, or to attend accident and emergency departments urgently or as an emergency via a 999 ambulance. That is, they offer advice on the urgency with which help should be sought, pass that call on if required, or offer advice about the management of a health problem. Typical examples would be a parent of a young child calling to ask whether the child needs to see a doctor immediately, or an adult calling to ask for advice on managing a self-limiting condition. To help nurses develop the skills required for such telephone triage, NHS 24 runs an extensive in-house training programme covering the use of the CDSS system, and the identification and response to potentially high risk clinical situations. In this study the dichotomous outcome variable of whether or not calls were sent to self-care was chosen because advice to 'self-care only' presents both callers and nurses with the clearest risk – that the patient will not be seen by a health professional and may be falsely reassured and their care delayed . Our hypIn April 2005, staff in NHS 24 compiled a list of the 542 nurse advisors employed in the service and sent a two-sided questionnaire to each nurse using the internal postal system. Questionnaires were accompanied by reply paid envelopes and returned directly to the research team. Up to two reminders were sent. Anonymised routine data on all calls undergoing clinical assessment during a six month period in 2005 were obtained from NHS 24, including date of call, time of call, age and sex of patient, triage decision, and identification code of the nurse advisor taking the call. This unique nurse identifier was used to match the triage decision data for an individual nurse to their responses to the questionnaire.reactions to uncertainty, that is the stress related to uncertainty and the reluctance to disclose uncertainty [A validated tool was required to measure attitudes to risk in nurses undertaking telephone assessment. This tool needed to address clinical decision-making in the face of uncertainty , and theertainty . The othertainty , specifiertainty ,11.A questionnaire was constructed which asked questions about the background and work practices of the nurse, as previously asked in a study of NHS Direct . It inclCognitive testing of the questionnaire was undertaken by asking four NHS Direct nurses to complete the questionnaire in the presence of a researcher and discuss problems with comprehension and reasons why they selected options. This resulted in changes to the instructions, and the options available for some questions. No changes were made to the risk section of the questionnaire but it was noted that nurses found it difficult to decide which option to select for some individual items. They explained that this was due to the complexity of decision-making and the wide range of situations faced by telephone assessment nurses. The questionnaire was then piloted on 25 nurses in an NHS Direct site. Item completion rates, and the spread of data within individual items, were good for the 13 responses received.First, a descriptive analysis was undertaken of the nurse characteristics. The adapted Grol instrument score was calculated to identify the proportion of nurses with a 'no risk-taking' attitude and to compare that with published data on doctors . Then an14% (78/542) of nurses were on maternity leave, long term sick leave, or had left the service, and therefore did not receive the questionnaire. This proportion was similar to that found in a survey of nurses in NHS Direct (94/517 = 18%) . After rDescriptive data on nurse characteristics are based on the 265 respondents to the questionnaire and are shown in Table Responses to the fifteen risk items are shown in Table Factor analysis was undertaken on these fifteen risk items. Two items were excluded due to low correlation with other items. Factor analysis was undertaken on the remaining thirteen items using Varimax rotation and then Promax rotation in case the factors were correlated . The samWe were able to link survey responses to call data for 251 nurses, of whom 211 had taken at least 100 calls in the relevant time period. These 211 nurses had taken a total of 231,112 calls. Calls were mainly triaged outside normal working hours and 16% were triaged to self care  declare that they have no competing interests.JM, COD, and DH conceived the study. JM and AOC designed the study. IA facilitated acquisition of data. AOC analysed the data. All authors contributed to interpretation of data and guided further analysis. AOC drafted the manuscript and all authors made critical contributions to further drafts. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Anopheles mosquitoes using the sterile insect technique (SIT) requires consideration of the full gamut of factors facing most proposed control strategies, but four criteria identify an ideal site: 1) a single malaria vector, 2) an unstructured, relatively low density target population, 3) isolation of the target population and 4) actual or potential malaria incidence. Such a site can exist in a diverse range of situations or can be created. Two contrasting SIT field sites are examined here: the desert-flanked Dongola Reach of the Nile River in Northern State, Sudan, where malaria is endemic, and the island of La Reunion, where autochthonous malaria is rare but risk is persistent. The single malaria-transmitting vector at both sites is Anopheles arabiensis. In Sudan, the target area is a narrow 500 km corridor stretching from the rocky terrain at the Fourth Cataract - just above the new Merowe Dam, to the northernmost edge of the species range, close to Egypt. Vector distribution and temporal changes in density depend on the Nile level, ambient temperature and human activities. On La Reunion, the An. arabiensis population is coastal, limited and divided into three areas by altitude and exposure to the trade winds on the east coast. Mosquito vectors for other diseases are an issue at both sites, but of primary importance on La Reunion due to the recent chikungunya epidemic. The similarities and differences between these two sites in terms of suitability are discussed in the context of area-wide integrated vector management incorporating the SIT.The selection of suitable field sites for integrated control of  The Sterile Insect Technique (SIT) is an option for inclusion in area-wide integrated vector management (AW-IVM) programmes, where and when the necessary criteria have been met and it is the best of the alternatives. For any control method, but in particular methods based on mass release, field site issues, such as difficult and extensive terrain, complex local vector bionomics and poor infrastructure, can necessitate reliance on broad assumptions and extrapolation, when a critical factor may lie in specific details.In contrast to efforts in the mid-1900s, modern evaluation of field sites benefits from substantial advances in technology and knowledge: Global positioning systems, geographic information systems and high resolution satellite images allow comprehensive storage and analysis of temporally and spatially referenced data relevant to vector bionomics and environmental variables .Anopheles arabiensis: the desert-isolated Dongola Reach of the Nile River in Northern State, Sudan and the French island of La Reunion in the Indian Ocean. While the uses of SIT at the two field sites are described as feasibility studies, it is not the technique itself that is in question, but rather the ability to surmount the successive practical and technical challenges of creating and sustaining an operational programme on a meaningful scale.This paper examines two contrasting field sites where studies to develop AW-IVM including SIT are underway for controlling the malaria vector The appropriateness of SIT for use at each field site is a separate consideration. This chapter focuses on field site evaluation leading to the choice of SIT, rather than whether or not it can be successfully implemented. Furthermore much of the evaluation of a field site is general purpose when it comes to malaria control, so while factors such as capacity building, existing entomological information and national support are important considerations, the focus here is only on the factors most pertinent to SIT.The problem was presented to a panel of experts at a meeting sponsored by the IAEA in Vienna in June, 2001 . The panEach of the criteria will be discussed below and considered in depth in relation to the field sites in Sudan and La Reunion. The criteria are a simple primary guide that illustrate an ideal situation, but a consideration of past studies and the two detailed examples will illustrate that disparate situations can be suitable for the development of SIT for use in the control of anophelines. Furthermore as SIT is used in the context of AW-IVM, the criteria of isolation and low density may be met through other control methods. The scope to find additional suitable sites is therefore substantial.Anopheles albimanus within one season from Lake Apastepeque in El Salvador, where isolation was promoted by the limited availability of larval breeding sites, bloodmeal hosts and shelter and by hills on two sides [Culex tarsalis populations in a canyon in California [Culex quinquefasciatus populations on islands off the coast of Florida [Even a small influx of inseminated females can significantly counter the suppression achieved by the released sterile males ,5. In idwo sides ,7. Culexlifornia  and Cule Florida ,10 were Cx. quinquefasciatus was eliminated within one season from a small Myanmar village surrounded by rice fields that were completely dry in winter [Aedes albopictus benefits from the absence of suitable breeding sites in open farmland surrounding the target villages [The first example of successful genetic control of mosquitoes illustrates how even temporary isolation may be exploited; n winter . A currevillages .Cx. quinquefasciatus population in two villages south of New Delhi [An. albimanus population in the second release programme in El Salvador where the Pacific coast and a mountain range provided the primary barriers [Aedes aegypti [Anopheles gambiae in the small village of Pala, near Bob-Dioulasso in Burkina Faso, relied on distance from neighbouring villages [Culex pipiens population isolated in a subterranean well in a small village near Montpellier, France [An. albimanus larval breeding sites forming at the mouths of drying up rivers (esteros) was not accounted for  and immigration into the release area exceeded expectations [Isolation can be enhanced or created artificially by source reduction, insecticide application and land use changes. An insecticide barrier was used to isolate a ew Delhi  and to cbarriers . Tyre du aegypti . Releasevillages . Slightl, France . The impctations .The need for isolation can limit the scope of SIT, but the above examples indicate the diverse nature of the sites targeted in the past. Table 2. Northern State, located in the north and bordered by Libya, Egypt and Chad, occupies nearly one fifth of the country and is the largest of the 26 states, yet has the lowest population density . It is very arid and almost entirely desert: rainfall is rare, whereas dust storms are common. Temperatures reach 47°C in summer and as low as 7°C at night in the winter.The Republic of Sudan is the largest country in Africa, covering 2.5 million kmThe Dongola Reach, between the Third and Fourth Cataracts, accounts for about two thirds of the length of the Nile within Northern State Figure . Above tAs all agriculture in this region is based on irrigation and the Nile flood, most of the State's people live alongside this stretch of the river, particularly within Dongola and Merowe provinces. Land under cultivation is more or less continuous along both banks varying in almost exact proportion with the human population density. Date palms predominate, while field crops are seasonal, being greater in winter when wheat and beans are grown, than in summer when maize and sorghum are common.Travel to, and in, Northern State is slow and difficult. Most roads are fair-weather earth and sand tracks, asphalt or gravel. A few years ago less than one third were paved, but this is changing rapidly largely due to the Merowe Dam Project (described more fully below). There are railway lines from the south via Abu Hamed in neighbouring Nile State to Kareima on the eastern state border and Wadi Halfa near the border with Egypt, but these no longer provide passenger service. There is a scheduled domestic air transport service to Dongola from Khartoum, and there are other airfields including one at Merowe that is being improved for regular commercial traffic.2. The project may be followed by construction of canals parallel to the river reaching as far as Dongola in a major expansion of irrigation-based agriculture.The Merowe Dam Project is the first stage of the largest development project in northern Sudan and is transforming the area. This hydroelectricity dam has been built on the Nile in the vicinity of Hamdab, north of Merowe. The reservoir is expected to cover an area of 711 kmAn. arabiensis is downriver beyond Dongola approximately 300 km south of the border with Egypt. It is kept in check by unsuitable terrain, low human population density, less favourable climate and the Gambiae Control Project (GCP), but occasional incursions of the mosquito as far as Wadi Halfa have been found.The northern edge of the distribution of An. arabiensis-free zone just south of the Egyptian border (which borders the SIT target area). Egyptian control activity in Sudan is a historical remnant of a major malaria epidemic in Egypt in the 1940s caused by the spread of An. gambiae s.l.  from Sudan. The mosquito was successfully eradicated, but could easily re-invade.Current mosquito control projects affect the suppression and isolation of the mosquito populations against which SIT is planned. They involve collaboration between the State Ministry of Health, the Malaria Administration and the GCP. The GCP is a joint protocol between the National Ministries of Health of Egypt and Sudan to maintain an An. arabiensis. The Yellow Zone to the south as far as Abri was the main focus of control operations. The Green Zone extended further south to Abu Fatma. The Red Zone has since been extended south to Abri, despite occasional discoveries of the vector. The Green Zone now encompasses Dongola.The current GCP was implemented in 1970 with the creation of three zones. The Red Zone, which extended north from Akasha, was considered to be free of In the past most control activities throughout the State involved local sanitation workers who removed or treated larval breeding sites. Larviciding and adulticiding was used extensively only in Dongola and further north where the GCP was operating. The Malaria Administration now has more direct involvement, and the GCP has expanded to cover the whole State. Nevertheless coverage is still very patchy, particularly upriver from Dongola.Mosquitoes are restricted by the desert to precisely the areas in which people live. Immigration via the desert is impossible and passive transportation via roads is improbable. Our efforts to transport mosquitoes by car for periods longer than about half an hour were only successful if precautions were made to control temperature and, for adults, humidity. The width of the cultivated areas is only a few kilometres, which provides scope for the creation of control barriers that can be extended in a rolling carpet fashion up or downstream.An. arabiensis along the Abu Hamad Reach, so the Northern State mosquito population is relatively isolated . The isolation will become complete as a consequence of the Merowe Dam. The reservoir lake will stretch for about 200 km along the previous course of the Nile and extend out into harsh rocky terrain and desert unsuitable for agriculture and human habitation. It will eradicate any mosquitoes in the area and pose a significant barrier to mosquito dispersal downriver for many years to come, if not indefinitely,The few relatively isolated villages and the inhospitable terrain above the Fourth Cataract limit survival and movement of The Nile Valley of Northern State therefore provides a field site no more than 500 km long and mostly less than 10 km wide that is well isolated by a combination of factors, but primarily the desert. The very limited opportunity for reinvasion through passive transportation can be addressed by modest surveillance and control efforts conducted some distance away at the start of the relatively few routes to the north.2. The human population is close to 800,000 and most live in coastal areas. The island was formed from two volcanoes  and almost three quarters of the land is above 500 m (Figure The island of La Reunion lies in the Indian Ocean, about 700 km from Madagascar and approximately 200 km southwest of Mauritius. La Reunion is 63 km long and covers 2,512 kmm Figure . Three dThe climate is mainly tropical, but varies with altitude and aspect. The east is exposed to the trade winds, which bring about 4-8 times more rainfall than in the west. The hot, wet season is from November to April when average temperatures are around 25°C and vary only a few degrees over a full day. Relative humidity remains high throughout the year, except in the west where it can reach as low as 50%. Cyclones in January and February are relatively common.Sugar cane occupies about 50% of the cultivated land, extending across the coastal lowlands and lower slopes of the mountains and accounts for 69% of all exports. Tourism is important and was badly affected by the recent chikungunya epidemic . About hAn. arabiensis is much smaller. There is again scope for a release programme to be carried out in stages as the vector is found within three distinct sectors covering about 100 km2 in the northeast, about 50 km2 in the northwest and about 30 km2 in the southwest (Figure On La Reunion, leaving aside passive transportation, the overall isolation of the mosquito population is not in question. The total area of the island is less than the proposed control area in Sudan, and the area occupied by t Figure . These aAn. arabiensis onto the island and between release zones via human transportation is an important concern and will become more so as vector free areas develop. In contrast to northern Sudan, survival of adult mosquitoes in cars is likely and travelling times are short. The risk of malaria and vectors becoming re-established via infected mosquitoes and people arriving at sea and airports is currently tackled by monitoring and control operations. If a successful control programme using SIT leads to elimination of the mosquito population, this will become the primary focus of subsequent anti-malaria efforts.Passive transportation of While it is possible to target more than one vector through the simultaneous release of sterile males of different species, reducing malaria transmission by release of a single species will be more cost effective. Density dependent regulation of the target vector has been recognised as a problem in past studies, because low density larval populations can lead to higher adult numbers compared to crowded breeding sites . This neAnopheles arabiensis is the only anopheline vector in Northern State [An. arabiensis showed significant differentiation between populations separated by more than 200 km [rn State . The mosrn State . Samplesn 200 km . TherefoAnopheles rufipes, Anopheles pharoensis and Anopheles multicolour, but all records of these species were made over fifty years ago and they have not been found since [An. arabiensis would affect the density of culicine species since their larval development sites overlap to some extent [The presence of several other anophelines has been reported, i.e. nd since . From the extent . There iAn. arabiensis was introduced to Reunion from Mauritius during a cyclone in the mid 1800s. Anopheles arabiensis is the only malaria vector on Reunion Island [An. arabiensis over large geographical distances on mainland Africa show differentiation, but as yet no published reports of distinct forms [Anopheles coustani - which does bite humans, but is not considered a potential vector of malaria on the island [The broadest collection of information regarding anophelines on La Reunion has been collected and synthesised by Girod . Based on Island . Studiesct forms . Only one island .An. arabiensis from La Reunion with samples from neighbouring islands and West Africa [A comparison of microsatellite DNA polymorphism in a sample of t Africa , and an t Africa  producedPast malaria control campaigns, heavily reliant on indoor insecticide spraying, have selected this mosquito to become exophilic and exophagic . The avaDespite the isolation and specific selection pressures, crossing studies between laboratory strains originally from mainland locations and La Reunion mosquitoes showed no evidence of incompatibility . The popGlossina austeni, from Unguja Island, where the population was suppressed with pyrethroids prior to using SIT [To attain and sustain the optimal release of sterile males it is vital to have good data on the target mosquito population density and distribution throughout the year and in response to changes in climate or other major factors such as the Nile flood in Northern State. In contrast to insecticide, SIT increases in efficiency as the density of the target population decreases, so SIT is a good option when the starting point is a low-density population. If the starting point is high density, then SIT will be cost effective at a later stage. This was illustrated by the eradication of the tsetse fly, sing SIT .An uneven mosquito distribution, especially with poor roads, limited or inaccessible terrain and long distances, may also favour the choice of SIT over insecticide in an area-wide approach. Both of the field sites described here illustrate the above points. In each case the target population is low density. The delivery of insecticide to the vector is hindered in Northern Sudan by long distances and difficult terrain and in La Reunion by a change in the vector's behaviour from endophilic to exophilic.An. arabiensis density are mainly determined by the flooding of the Nile and changes in ambient temperature [An. arabiensis. As the river level falls, suitable breeding sites form, but low winter temperatures delay the resurgence in mosquito numbers. By March, the river level is down almost to its minimum, but the temperature has not yet reached the summer maxima resulting in the peak of An. arabiensis density. A month later the temperatures are much higher and mosquito numbers drop to an intermediate level which is mostly sustained throughout the summer until the flood [The temporal and spatial changes in perature . The Nilhe flood ,24.The location, relative timing and magnitude of these events may be critical, since past studies in Upper Egypt record quite a different pattern . An earlAnopheles arabiensis was most reliably found in riverbank pools surrounded by grassy vegetation. The low-lying grassy banks are undulating, so pools form and slowly dry up as the river level drops. Some may remain throughout the summer, particularly if they are connected to the river underground, or are deliberately maintained to facilitate irrigation. These are common, but there are also long stretches of very steep river bank, where An. arabiensis larvae are almost never found. All other breeding sites are the consequence of human activity, usually associated with poor maintenance and distribution of water supply; however these are also influenced by seasonal factors and by location. In particular, water conservation, such as irrigation of fields in rotation and limiting water supplies to houses for part of the day, is more extensive in summer months. Small villages may have very little plumbing, less reliable water supplies and many houses may be uninhabited, whereas in places like Dongola, Merowe and Kareima the number of larval breeding sites associated with leaking pipes is more likely to correlate with the size of residential areas.Extensive studies of larval development sites have been completed and provide a valuable source of detailed information about their temporal and spatial characteristics . The rivAn. arabiensis. However, there is enough scope for An. arabiensis to continue breeding throughout the year, and the available vector density and malaria incidence data indicate that this is the case. It is unlikely that aestivation occurs [There is also more agriculture associated with the larger urban conurbations, with more substantial and reliable canals extending much further from the river. Due to water flow, conservation and high temperatures the irrigation channels rarely provide larval breeding sites, even where run-off pools form from poor maintenance. Occasionally, larvae are found in pools that form from leaking water pumps that supply the channels. In both cases the water is usually dirty and unsuitable for n occurs ,31, althAnopheles arabiensis breeds throughout the year, with a slightly lower density occurring during the cooler dry season.While the Sudan analysis is based on recent surveys, the data for La Reunion is temporally extensive and spatially detailed. As of 1985, all actual and potential breeding sites surveyed have been placed into six categories with spatial and temporal references and entered in a geographical information system. The main breeding sites are partially dry river beds and puddles formed from wheel ruts in the sugar cane fields. There are no breeding sites found above 600 m, although these did exist in the past when the mosquito population was much larger. Malaria in Northern State appears to occur throughout most of the year with a peak incidence in May or June, but most of the available data are based only on admissions to the 26 clinics and hospitals. These records are not detailed, nor necessarily reliable due to a lack of robust diagnosis, and all locations do not follow a predictable pattern. Wadi Halfa hospital is particularly notable, since it has malaria admissions in similar proportions to other hospitals, yet it is in an area where the vector is not present. This could be explained by large numbers of travellers en route to and from Egypt and the exchange of visits with relatives in New Halfa. At other hospitals, unusual peaks in the data could be due to an influx of casual labour for harvests or development projects. At present, it is difficult to assess the amount of malaria transmission actually occurring in Northern State; that it is occurring and that it is significant is not in doubt .The lack of detailed data on malaria case histories in Northern State means there is only anecdotal information on the location of high-risk areas. For example it is not possible to assess if risk is greater in residential areas close to the riverbank surrounded by fields or palm groves than those further away surrounded by desert. There is also no published information on dispersal of the vector so one activity of the National team is to perform mark-release-recapture measurements, the data from which are now being collected. Another part of the National effort to support preparation for SIT is to perform more extensive malaria surveys and to use better diagnostic procedures and equipment, and to provide training in the clinics and hospitals.From a national perspective, malaria control in northern Sudan requires as much if not more resource input than in other areas to tackle a far less severe problem. It is nevertheless an important area for the national economy and one with considerable potential for further investment and development. From a regional perspective malaria in northern Sudan and Northern State in particular, is also important, because it poses a threat to Egypt and Libya.On La Reunion malaria was once well established across much of the island, particularly in urban areas . A contrPlasmodium falciparum. Moreover, the continuous significant expenditures on vector surveillance and control increase the attractiveness of an SIT programme, particularly if it resulted in elimination. Annual expenditures prior to the modern chikungunya epidemics were estimated at € 3,350,000 per annum, 70% of which was dedicated to vector control [It is, therefore, now more than 25 years since the residents of La Reunion were routinely exposed to malaria infection, and only rarely do autochthonous cases occur. Since up to 170 travellers infected with malaria arrive on the island every year, the risk of an outbreak is significant and could result in high mortality, especially as the predominant infection is with ® is applied to positive and potential larval breeding sites in the vicinity of the harbour and airports with additional adulticiding in and around the houses of definite, or likely, malaria cases.The current anti-malaria campaign is carried out by La Direction Régionale des Affaires Sanitaires et Sociales. It involves the monitoring of all travellers from known malarious regions with a free service of blood tests and advice on appropriate treatment. AbateThe facilities for sterile male production for Northern State will be in Khartoum, close to an existing radiation source and the scientific institutions with the necessary expertise and trained technical staff needed to support the programme and where supplies and maintenance for the building, equipment and utilities will be more reliable. This will entail a four- to six-hour overland journey, all of it through the desert and at high ambient temperatures most of the year. Transport by air is feasible and may also be favoured for releases, although this has never been done with mosquitoes. The river is another option for the distribution from a delivery centre to release points and likely to be the most practical. This concept echoes an old idea: in 1907, the Wellcome Research Laboratories based in Khartoum, outfitted a boat called "Culex Pipiens" as a floating laboratory to overcome the many problems of field work and this approach has also been adopted by the GCP in Egypt.La Reunion has better infrastructure for weather monitoring and prediction and both local and international communications. Expertise on insect pests and research facilities are well established on the island, whereas in Sudan most relevant expertise and facilities are based in Khartoum, although research on agriculturally important pests is reasonably well served within Northern State.Capability strengthening is critical and must be considered at all levels, even retraining the most unskilled to gather new useful information. On La Reunion the obvious solution is that those involved with the current control programme will take the principal role in developing and implementing field operations. In Sudan, this is much more complex, the current control effort in Northern State involves three organisations and the development and delivery of the SIT project will involve at least another six. All efforts must be made to eliminate unnecessary duplication of effort, competition and misunderstanding.There are no safeguards against unexpected events that could have a dramatic impact on a release programme, but it does help to identify known risks. The occurrence of cyclones on La Reunion is an obvious example; these can bring very heavy rainfall and damaging winds. Sandstorms are a similar problem in Northern State. Less frequent and equally irregular are flash floods, very high river floods due to heavy rainfall in the Ethiopian Mountains and breached flood defences. These affected Northern State in 1988, 1994, 1998 and 1999. In 1998, 28,000 people were left homeless. In 1999 the riverbank south of Dongola broke, flooding 90% of the town and destroying five villages . These e• Containment of release zones will require monitoring of transport, development projects, seasonal traffic and research on natural and artificial barriers.• Other control measures should be integrated with SIT as standard, but in addition consideration is needed for initial population suppression, artificial barriers, control of other vectors and as part of contingency plans in the event of a breakdown in the SIT programme.• Assessment and periodic reassessment of single vector status versus its population structure, secondary malaria vectors and vectors of other diseases.• Population size, density and distribution in relation to terrain, climate and river levels, nature of larval breeding sites and human influence, vector behaviour and physiology.• Operational logistics of transport and release of sterile males; organisation, capability strengthening and training for SIT and integration with existing vector control.• Malaria incidence, geographic origin and cost.• Unpredictable events, at least in the long-term, such as flash floods, sandstorms and cyclones.While both of these two field sites meet the criteria for SIT, they could not be more different. For vector control, La Reunion has some advantages compared with Northern State in terms of size and accessibility, in infrastructure, resources and technology and in the existing knowledge base for vector bionomics. However, the impact on malaria in Sudan will be greater, the reduction in risk to neighbouring countries substantial and an area with exciting development prospects of national importance will be freed of a significant hindrance to progress.Some people might be tempted to conclude that areas such as these are unique, and that even if SIT is proven to be a valuable component of AW-IVM, it will be restricted to relatively unimportant status because its application will be limited to such unusual locations. SIT is, of course, not a stand-alone, off-the-shelf generic tool for mosquito control, but the diversity of the two sites considered provides an indication of just how different suitable field sites can be. When the range of field sites in related studies several decades ago is considered Table , it is nFrom another perspective, the projects described here are small and will start very small, but success in Northern State could see an extension of the programme to neighbouring River Nile State and perhaps even to Khartoum and its environs. Success on La Reunion could see an extension to other islands in the Indian Ocean. The long-term prospect is a very large area not only free of malaria, but free from the risk of a return of malaria.The authors declare that they have no competing interests.C. Malcolm composed most of the text and summarized many of his personal observations regarding Sudan. The remaining authors reviewed and approved the content.


There is on-going controversy in relation to the efficacy of naltrexone used for the treatment of heroin addiction, and the important covariates of that success. We were also interested to review our experience with two depot forms of implantable naltrexone.A retrospective review of patients' charts was undertaken, patients were recalled by telephone and by letter, and urine drug screen samples were collected. Opiate free success (OFS) was the parameter of interest. Three groups were defined. The first two were treated in the previous 12 months and comprised "implant" and "tablet" patients. A third group was "historical" comprising those treated orally in the preceding 12 months.There were 102, 113 and 161 patients in each group respectively. Groups were matched for age, sex, and dose of heroin used, but not financial status or social support. The overall follow-up rate was 82%. The Kaplan Meier 12 month OFS were 82%, 58% and 52% respectively. 12 post-treatment variables were independently associated with treatment retention. In a Cox proportional hazard multivariate model social support, the number of detoxification episodes, post-treatment employment, the use of multiple implant episodes and spiritual belief were significantly related to OFS.Consistent with the voluminous international literature clinically useful retention rates can be achieved with naltrexone, which may be improved by implants and particularly serial implants, repeat detoxification, meticulous clinical follow-up, and social support. As depot formulations of naltrexone become increasingly available such results can guide their clinical deployment, improve treatment outcomes, and enlarge the policy options for an exciting non-addictive pharmacotherapy for opiate addiction. Ever since the pathfinding studies in New York of Dole and Nyswander  and collNaltrexone is one alternative which has existed for several decades but is rarely used. First synthesized by Matossian at Endo laboratories in 1963 , it was It has been hoped that many of these compliance problems will be overcome by the recent development of depot formulations of long acting naltrexone injections and implants . This waWe were therefore interested to compare our early experience with a one month depot device from the USA, to the "Go Medical" implant from Perth, and to compare this experience in turn with the concurrent and historical experience with the oral formulation of naltrexone. Some of these results, and important lessons for patient management which follow from them, are presented in the following report. Serum levels of naltrexone, serious adverse events, and the experience with buprenorphine in the office management of opiate dependent patients are presented in companion papers.The study was performed on patients presenting to a low cost private naltrexone clinic in Brisbane, Australia. The program had been in operation for over three years at the time the study was performed. Patients were divided into three groups on the basis of when they were treated and the primary treatment modality employed. Patients were not randomized. Group selection during the later period was mainly made on financial status, determined by the ability of patients' families to afford the implants. The three groups defined were:1) "Implant": Patients having a naltrexone implant March 2000 – March 2001. Some of these implant patients had first been treated at earlier time points;2) "Tablet": Patients treated with oral naltrexone March 2000 – March 2001;3) "Historical": Patients treated with oral naltrexone 12 months prior to the recent period, March 1999 – March 2000.In order to control for the effects of the passage of time it was felt important to keep the two oral naltrexone groups separate for most of the analysis as indicated, particularly in view of the changing heroin supply in Australia over the period of this study.Assignments of various psychosocial indicators was made by the treating clinician based on information disclosed during the time of patients' presentations to the clinic, and documented by retrospective review of patients' charts. Financial status, social support and spiritual belief were assigned in three groups. Patients' financial status was assigned into three strata: "pensioner" relating to those on social security alone; "average" relating to those in socioeconomic class III-V, and "white collar" relating to those in socioeconomic class I-II. The strength of social support networks were graded 1, 2 or 3 depending on the availability of mature adult responsible carers in the patients life, and the access of the patient to those carers. Sport and employment variables were assigned on a simple presence or absence basis. For the purposes of urine drug screening, the most recent result in the patient's file was the one analyzed. Spirituality was defined as religiosity and was assigned on the basis of declaration of belief in traditional religious belief  (scored "2"), traditional belief and consistent practice (scored "3"), or nil, atheist or pagan (scored "1").The Rapid Opiate Detox and induction onto naltrexone was performed after the method of O'Neil which is similar to that approved by the NSW Health Department ,48. ThisOral naltrexone tablets were used. These are the 50 mg "Revia" tablets from Du Pont, obtained in Australia from the Orphan Drug company. It was a condition of treatment in this clinic that all patients presenting for naltrexone treatment brought with them a responsible mature adult drug free carer who could supervise oral tablet administration on a daily basis, or assist with the implant process where that option was chosen. Implants were obtained from two sources both presently provided as a pre-loaded syringe. The American implants are a single pellet containing 1 g of naltrexone and were obtained from the Wedgewood Pharmacy, 405 Heron Dr. Suite 200, Swedesboro, New Jersey, USA, 08085-1749. The Australian implants contain 1.1 g naltrexone, and release about 0.4% of their dose daily. It was obtained from "Go Medical" in Perth, 200 Churchill Ave, Subiaco, Western Australia, Australia, 6008. It is also presented as 10 pellets in a sterile pre-loaded syringe.Naltrexone implants were inserted subcutaneously after the method of Brewer. The implant may be inserted at any time after the commencement of naltrexone when the patient is stable and restful. In essence implant insertion involves the use of sterile surgical technique and local anaesthesia  to make a 1.5 cm incision in the skin, and the development of a 10–12 cm. long subcutaneous tunnel by blunt dissection. The sites chosen may vary, but the most suitable are the skin of the lower abdomen or the lateral chest wall with an incision below the hair of the axilla. The pre-loaded syringe is then inserted into this space and the contents discharged. The skin is closed with two or three vertical mattress sutures.st March 2001. Patients were followed up either in the normal course of their clinical review protocol, or for patients who had ceased clinic attendance, by formal recall by telephone and in writing. The date of the last naltrexone purchase was also obtained and factored into the calculation of the patient's likely clinical status. Urine samples and independent reports from their carer were used to verify patients' self-report. A carer was defined as a mature responsible drug free adult who was able to supervise the administration of all medication, and particularly to crush the naltrexone tablet daily and supervise its administration. The primary measure of satisfactory progress in these patients was "opiate free success." This was defined as a composite measure including having a urine drug screen negative for opiates by Thin layer Chromatography or having a carer report satisfactory progress. The date of final contact was taken as the latest of the last clinic visit, the last telephone contact, or the last naltrexone tablet to be purchased, as determined by pharmacy records. As reported below it was possible to follow up most patients. However where patients could not be followed up positively every patient was assigned a score based on how it was believed they had progressed, either on the report from their family, or the report from other patients in their network. Patients for whom no data was available or who were known to have relapsed to regular heroin or methadone use were presumed to have failed treatment.The period of follow-up was defined as one month before and after 1All data was obtained by retrospective review of patient charts after deliberate follow-up as described. Data was entered into Microsoft Excel spreadsheets. It was analyzed by several programs, particularly the survival and failure time analysis module of Statistica. The modes used in this module were the two sample, k-samples, and Cox proportional hazard multivariate models. Key statistics calculated were the WW statistic, the sum of scores of the differences between R1 and R2 being the number of scores below and above each score respectively, and Gehan's modification of the Wilcoxon test statistic. The statistical programs EpiInfo , the Mann-Kendall test for trends ,50 incluThis study was undertaken as part of a retrospective clinical audit of patients treated under semi-urgent conditions. Implant patients were treated under the special provisions of the Australian Special Access Scheme of the therapeutics Goods Administration in Canberra A.C.T., Australia. The study was approved by the clinic Human Research Ethics Committee, National Health and Medical Research Council registration number #000409. No procedure was performed on patients which would not have been done in the normal course of their clinical care. All patients were treated with their own informed witnessed consent. Only disidentified aggregated data is presented.There were 102, 113 and 161 patients in each of the implant, tablet and historical groups respectively, a total of 376 patents. Various follow-up and demographic criteria are presented in the accompanying Table When however the financial and social status of the three groups were compared significant differences were revealed between the various groups. These various ratios are given in the later part of Table The follow-up rate was 82% overall. The overall urine drug screen follow-up was 76%. The proportion of patients in each group whose urine tested positive for naltrexone was 70%, 52% and 39% respectively and 50.4% overall. The re-treatment rate of all patients attending this clinic is 1.4 (1301 treatments in 902 patients). The numbers of patients having various numbers of implants is indicated in Table Figure Table Table Review of spiritual status of patients after treatment revealed that 65%, 26%, and 9% scored 1, 2 and 3 respectively, with no significant differences in between group distribution.Table Clearly however the central issue relates to relative importance of these various factors. A multivariate survival analysis was performed which demonstrated that social support, the number of detox's, work after treatment, type of implant, the number of implants and spirituality continue to be significant. When a similar analysis was performed limited to implant patients alone, social support, work prior to treatment and the presence of cannabis in the urine were significantly related to opiate free success.This study has been performed as part of an ethically approved clinical audit of the opioid treatment program in this clinic and makes pertinent comparisons between rates of opiate free success in patients treated with implant and orally administered naltrexone as well as a variety of psychosocial and treatment parameters. Factors which were noted on bivariate analysis to be significant were in order were employment subsequent to treatment, the number of detox episodes, the level of social support, the number of implant episodes, whether implants or tablets were used, the use of multiple implants, the type of implant (including no implant), spirituality, the financial status of the family unit, the presence of morphine in the urine, the presence of naltrexone in the urine, negatively correlated with the presence of olanzepine in the urine and the semi-quantitative presence of naltrexone in the urine Table . On multWith the increasing availability of long acting and depot preparations of antagonists onto the pharmaceutical market some guidelines for their application would be most useful. It must be noted in considering the outcome analysis of this study that the form of the present work was a retrospective chart review. Patients were not randomized and there were notable differences between the groups at enrolment in social support and financial status which were related to having to fund the cost of the treatment including implants. Given this important limitation there are a number of indications from this data which are useful for directing clinical practice, and may be tested in well designed randomized clinical trials. Strengths of this study included the relatively high overall follow up rate of 82%, the relatively large patient numbers reviewed, the breadth of treatment and psychosocial factors examined, and the various formulations of naltrexone used.The major point of this study is the remarkable success of sustained implant therapy. 88% of the Perth implant patients and 78% of the USA implant patients were opiate free at 12 months. Our data clearly indicates that repeated episodes of detoxification and of implant insertion are important contributors to opiate free success and to the long term engagement with patients whose long term course is recognized to be marked by periodic relapse. This notable success rate suggests a potential alternative to other management streams for refractory opiate dependence such as rehabilitation where places are typically limited, and incarceration with all its attendant costs and problems. This latter option has been extensively discussed ,54.We did not find a difference in the two types of implant used. Whilst this may be due to considerations of statistical power, the null hypothesis cannot be confidently excluded on the basis of the present data. It is noteworthy that the surgical procedure for implant insertion is straightforward. Since this study was completed the usual technique has changed in that rather than precipitate an acute detoxification syndrome under sedation using oral or parenteral antagonists as described here, a generally milder procedure is performed where the implant itself is used to detoxify the patient. As the serum levels achieved with the subcutaneous route are lower than those seen with alternative routes in well prepared patients, this technique is easier and much faster, and suited to ambulatory use.We were pleased to note a 54% opiate free success rate for tablet administration which is higher than that reported from many other centres. However it should be noted that this figure includes supervised and assisted administration of the tablet by a significant other individual, opiate free success rates rather than simply retention only, and repeated episodes of detoxification and treatment initiation. Whilst this is a very different design from most naltrexone studies in the literature, it is nonetheless normal practice in both other addiction pharmacotherapies and most drug free rehabilitation programs. Careful involvement of the residual functional social network is an important buttress to pharmacological treatment, including supervision of the taking of the oral tablet, crushing the tablet and intensive medical supervision of minor side effects in the early post-treatment period, which all appear to be important to optimize results. The involvement of supervision might explain the classical rather paradoxical perception that naltrexone appears to work best for professionals and recent prisoners , which sThe literature experience with SSRI antidepressants appears mixed ,57. In tThe significant and dramatically increased rates of work involvement after treatment is gratifying. This is also of therapeutic importance in that it was shown to correlate with success in both univariate and multivariate regression. Privileged financial status (as defined in the Methods section) whilst having some bearing on success in a bivariate study, was shown not be significant when treatment success was controlled for social support and spirituality, which appeared to be the proximate underlying and determinative variables.The prominence of spirituality in the statistical analysis of this study is of some interest. This area is increasingly becoming a focus of research interest in recent times ,59. ProbAs mentioned above this paper does not discuss adverse outcomes which are addressed in a companion study. In general terms it can be said that this clinic has not encountered a mortality concern with these long acting implants in the present experience no patient has died related to causes which are attributable to the implant. A useful margin of safety however must form a pillar of successful adoption of a new treatment if it is to be widely deployed. The recent study of the Perth cohort by Hulse was noted above, and the overall mortality risk of naltrexone implant management was shown to be at least as low as that of methadone maintenance . A furthThere are several limitations of the above study. Some of these relate to the design limitations of a clinical audit review. These would include the non-randomized nature of the study, the use of historical controls, and the need of patients to provide both drug free carers to supervise their treatment, and to fund the costs of their treatment themselves. One limitation mentioned above was the smaller numbers of patients with Perth implants which may have lacked statistical power to define a difference between the two implant types. There are several indications that the experience reported herein is preliminary in that this clinic lacks associated services which may be found with larger programs such as counsellors, integrated Hepatitis C care, gynecological care  and assiA further physiological point of some interest is the general consideration of the health effects of naltrexone, which in general may be said to be opposite to those of opiates. The effect on tissue growth and cell division are of particular interest although they would appear to have received little research attention . In thisEvidence of quantitative circulating stem cell deficits in addiction , togetheIn summary, this study confirms extensive literature experience that both oral and implantable naltrexone can be used with gratifying results in a primary care setting. Open access to affordable treatment appears to be important to ensure maintained success rates. The observed 12 month opiate free success rate of 54% with tablets could possibly be raised to 82% by the use of subcutaneous implants. Whilst it seemed to the clinician involved that the longer lasting Perth implants may be superior to those which are presently in more widespread use, the present study evidently lacked sufficient statistical power to show this. Ready access to repeat treatment and particularly repeat depot implantation would appear to be key components of a program seriously endeavoring to deliver high quality outcomes, and would appear to have the capacity to dramatically raise the treatment potential and patient appeal of naltrexone therapeutics. It is important not to overlook likely benefits to health of such medium term opiate antagonism including immunostimulation and recovery of cellular growth and organismal dysfunction which is likely to have accrued over a period of drug dependency. Employment after treatment, cannabis use, and spiritual development were all shown to be significant. It would seem likely that in the future implants will become the route of administration of choice for naltrexone. Subsequent to the completion of successful trials in the USA and Perth, extension of these findings in opiate dependent populations in prospective randomized multicentred trials would appear to be the logical next step for research and development in this area. Long acting injections, and depot delivered antagonists for other drugs of addiction appear to potentially hold therapeutic promise and might prove to be the way of the future.Dr. Reece reports that the naltrexone implants mentioned in this study were sold for use in patients from his clinic during the period of this study.ASR conceived and designed the study, perfoemed the literature review, coordintaed the follow up, drafted the manuscript, perforemed the statistical analysis, and constituted the graphical illustrations. He has read and approved the final manuscript.