During the 1990s, researchers at the Navrongo Health Research Centre in northern Ghana developed a highly successful community health program. The keystone of the Navrongo approach was the deployment of nurses termed community health officers to village locations. A trial showed that, compared to areas relying on existing services alone, the approach reduced child mortality by half, maternal mortality by 40%, and fertility by nearly a birth — from a total fertility rate of 5.5 in only five years. In 2000, the government of Ghana launched a national program called Community-based Health Planning and Services (CHPS) to scale up the Navrongo model. However, CHPS scale-up has been slow in districts located outside of the Upper East Region, where the “Navrongo Experiment” was first carried out. This paper describes the Ghana Essential Health Intervention Project (GEHIP), a plausibility trial of strategies for strengthening CHPS, especially in the areas of maternal and newborn health, and generating the political will to scale up the program with strategies that are faithful to the original design.GEHIP improves the CHPS model by 1) extending the range and quality of services for newborns; 2) training community volunteers to conduct the World Health Organization service regimen known as integrated management of childhood illness (IMCI); 3) simplifying the collection of health management information and ensuring its use for decision making; 4) enabling community health nurses to manage emergencies, particularly obstetric complications and refer cases without delay; 5) adding $0.85 per capita annually to district budgets and marshalling grassroots political commitment to financing CHPS implementation; and 6) strengthening CHPS leadership at all levels of the system.GEHIP impact is assessed by conducting baseline and endline survey research and computing the Heckman “difference in difference” test for under-5 mortality in three intervention districts relative to four comparison districts for core indicators of health status and survival rates. To elucidate results, hierarchical child survival hazard models will be estimated that incorporate measures of health system strength as survival determinants, adjusting for the potentially confounding effects of parental and household characteristics. Qualitative systems appraisal procedures will be used to monitor and explain GEHIP implementation innovations, constraints, and progress.By demonstrating practical means of strengthening a real-world health system while monitoring costs and assessing maternal and child survival impact, GEHIP is expected to contribute to national health policy, planning, and resource allocation that will be needed to accelerate progress with the Millennium Development Goals. Ghana has a long experience with evidence-based health systems development. During the early 1990s, debate about practical means of achieving the World Health Organization’s goal of “Health for All by the Year 2000,” led the Ministry of Health to implement an experimental maternal and child health program in Kassena-Nankana District of the Upper East Region (UER), Ghana’s poorest region. The program, known as the “Navrongo Experiment” was based at the Navrongo Health Research Centre, which due to its past involvement in international public health research, had a Demographic Surveillance System (DSS) that regularly conducted continuous monitoring of mortality, morbidity, and fertility dynamics in this largely rural Sahelian area. By 1998, preliminary results of the Navrongo experiment had begun to demonstrate that the project would have an impact. In the initial five years, fertility declined by about a birth from a total fertility rate of 5.5 and the maternal mortality ratio declined by 40% [The program’s success was based on at least two key features. First, it offered life-saving services delivered in a convenient, low-cost, and effective manner. Estimates derived during the Navrongo experiment suggested that the program, if faithfully scaled up, would add only $2.92 per year per capita to the revenue budget to launch, and an additional $1.92 per capita to current spending to sustain over time. Second, through community mobilization activities — especially with men — the program built a climate of trust between community health workers and extended families. Whereas clinical workers are required to extract fees from parents at the time of care, the community engagement system enabled community-based workers to trust clientele to eventually reimburse the system for pharmaceutical costs, even if families lacked cash at the time of care. This “trust as insurance” system ensured that extended families could be trusted to support emergency health care costs. Moreover, community engagement overcame “gatekeeping” of women’s health-seeking behavior. When women and children become ill in profoundly gender-stratified societies like those of northern Ghana, they are often denied the timely provision of simple, life-saving interventions because their elder women or male relatives are reluctant to allow them to seek care immediately [Despite the success of the Navrongo Experiment, the policy relevance of results was questioned by many district, regional, and national program managers. To address this skepticism, the district health management team (DHMT) from the Nkwanta District of the Volta Region launched a replication trial of the Navrongo experiment . ImplemeThe primary staff resource for Community-based Health Planning and Services(CHPS) are nurses, termed community health officers (CHOs), who spend 18 months in training schools and carry out an additional six-month internship for developing community liaison skills. CHOs are provided with essential equipment and assigned to health posts where they live and conduct doorstep services. This involves treatment of malaria, acute respiratory infections, and diarrheal diseases termed integrated management of childhood illness (IMCI). CHOs also provide comprehensive childhood immunization and family planning care for oral, injectable, and barrier contraception. CHOs live and work in health posts built with donated materials and the labor of community volunteers, and they are provided with a motorcycle. As resources become available, health posts are often upgraded or reconstructed as permanent structures that replace makeshift community-provided facilities. Volunteers care for diarrheal diseases, but they are mainly health promoters and referral agents who balance nurse outreach to women with a focus on the information needs of men and organizational activities. To support their work, these volunteers receive a bicycle.CHPS occupies the “ground level” of the health system. Both CHOs and community volunteers provide services at the doorstep and at community health posts. As in the rest of the Ghana Health Service (GHS), trained paramedics provide care at sub-district health centers, serving roughly six to 10 villages or 20,000-30,000 people, and clinicians provide surgical and other specialty care at district hospitals. Of the three districts– Garu-Tempane, Bongo, and Builsa – in the Ghana Essential Health Interventions Project (GEHIP) , Garu-Tempane lacks a hospital and medical coverage. Financial management and policy guidance is provided by a district health management team comprised of a District Director of Health Services and officers responsible for disease control, nursing, clinical operations, and nutrition. Supplemental funding for CHPS is sometimes provided by Regional Health Administration (RHA) resources, but uniform standards for such support is lacking.The Navrongo experiment demonstrated the limitations of basing child survival programs on access to commodities and/or clinical care alone. In one of the three study areas, briefly trained, unpaid volunteers were deployed to refer cases and provide antipyretics, vitamins, and other non-prescription drugs. Over the short-term, child mortality actually rose in this area compared to a control area where no interventions were offered, other than those routinely offered by the GHS. Research subsequently showed that syndromic intervention by credible but poorly trained volunteer workers delayed parental health seeking for effective curative care . Only whProperly trained and equipped community health workers can have health equity effects. In the Navrongo experiment, nurse care offset the detrimental effects that low parental-educational attainment and relative household poverty had on immunization, health-seeking behavior, and child survival. Volunteer services had no comparable equity effects . HoweverGhana aims to expand CHPS to all communities by 2015 with finances provided largely through government resources, although there is no health-sector budget provision for the cost of launching CHPS. Additional support is provided by NGOs, district assemblies, and the global community. Facility costs, equipment costs, and special start-up investments are not routinely available. But, flexibility for financing these costs exists in the development sector. In particular, development revenues of the World Bank, the European Union, and some bilateral donors are committed to flexible revenue accounts managed by decision makers with the District Chief Executive and District Assembly development. Whereas policies of the “Sector Wide Approach” once provided flexible revenue to district health managers, all fiscal flexibility is now managed by district political authorities. This pool of resources is combined with the government of Ghana’s flexible financing as well as by communities in the form of material and volunteer labor. Taken as a common fund, this source of revenue provides crucial district development resources that are external to the health sector but could be used to finance the essential $2.92 per capita in CHPS start-up costs. Since only about $14 per capita is available for all health expenditures combined, any meaningful contribution to the $2.92 per capita represents a major catalytic investment in CHPS expansion [Where CHPS leadership is well-articulated, district political commitment has directed resources to the $2.92 per capita incremental start-up costs. Exchanges between districts have been critical to demonstrating effective means of developing this commitment. By 2008, CHPS implementation had commenced in all of Ghana’s districts, but scale-up within districts had stalled or was incomplete nearly everywhere. CHPS, as it was originally envisioned, was reaching only 12% of Ghana’s households . Where RThe fundamental problem was that CHPS was originally conceived as a community-based trial focused on identifying the best way of delivering services and sustaining community engagement for primary health care, rather than a systems initiative that involved interventions for developing district and regional leadership. Research on CHPS was focused on identifying the best way of delivering services and sustaining community engagement for primary health care. However, scaling up CHPS is a district systems issue and requires improved capabilities in regional and district management, planning, budgeting, and resource development. This, in turn, requires political mobilization beyond the community level.In addition, fidelity to the original CHPS model developed at Navrongo has dissipated with passing time — a scaling-up phenomenon noted elsewhere -13. For The package of services was also often incomplete and proven life-saving components were needlessly excluded from the regimen. For example, supervision of nurses and volunteers was inadequate in many districts and information systems were so cumbersome that they were useless to CHOs. Another problem was that district leadership often prioritized ambulatory clinical care of adults rather than building community and political engagement to encourage community-based preventive health services and early treatment of the leading causes of childhood morbidity. In addition, owing to official National Nurse Midwife Council objections, CHO training excluded emergency obstetric care — life-saving skills, such as the management of asphyxiation and haemorrhaging, and proven approaches to saving newborn lives. In CHPS zones that were as yet incomplete, IMCI services were often inaccessible because there was no CHO. Volunteers might have been able to provide some of these services, but since they were often poorly trained and supervised, the GHS did not allow them to provide antibiotic therapy.Thus, despite evidence that community-based primary health care was scalable and affordable, health conditions remained needlessly poor. According to national statistics at GEHIP baseline, infant mortality was 50 per 1000 live births and under-5 mortality was 80 per 1000 person-years . HoweverGEHIP is a quasi-experiment designed to test the proposition that a novel set of interventions could improve the impact of CHPS, accelerate its adoption by districts, and, thereby, improve the health and survival of children under 5. Its interventions are informed by a prior initiative in Tanzania, known as the Tanzania Essential Health Interventions Project (TEHIP), which developed and tested tools for evidence-based planning, resource mobilization, and district health system leadership. GEHIP is posited on the assumption that improved planning, resource allocation, and leadership will accelerate CHPS, improve CHPS functioning, and reduce mortality as a result. During the 1990s, TEHIP was shown to have significant effects on child health and survival in that country, but its main potential for contributing to Ghana was its success in scaling up. Within a brief period, TEHIP transformed national management training, planning, and resource mobilization in all 120 districts of the country . In the In the UER, GEHIP interventions are led by Dr. John Koku Awoonor-Williams, the Regional Director of Health Services, and managed by a secretariat based at the UER/RHA. Nationally, GEHIP is supported by the Director General of the GHS and conducted in collaboration with the GHS Policy, Planning, Monitoring and Evaluation (PPME) Division, which develops national health policy. PPME also led the engineering of a new budgeting and planning technology known as the District Health Planning and Reporting Toolkit (DiHPART), based on a system originally developed in Tanzania by the Ifakara Health Institute (IHI) and the University of Dar es Salaam Computing Centre. The University of Ghana School of Public Health (UGSPH) and Columbia University’s Mailman School of Public Health (MSPH) contribute research and scientific technical expertise to the project. Scientists at the Navrongo Health Research Centre (NHRC), a field station of the GHS, conduct monitoring and evaluation research.Since so few districts are available for the selection process, GEHIP is a plausibility trial rather than a true experiment. Contrasting baseline conditions will require statistical adjustment at the close of the project. GEHIP iNational survey research and review of Navrongo long-term trends showed that neonatal mortality has declined more gradually than post-neonatal mortality. GEHIP has, therefore introduced the Save the Children “Saving Newborn Lives” intervention package for both nurses and volunteers . This inProcedures for data collection have been simplified with the elimination of gratuitous registers and forms in conjunction with the development and testing of a new health management information system (HMIS) known as the District Health Information Management System (DHIMS-2). Designed to support the decentralization of the health care system, DHIMS-2 improves the flow of information and supports the integration of health service operations. With the completion of GEHIP register simplification, DHIMS-2 addresses the need of community-based health care workers for simple and accessible information for supporting routine service delivery operations. Previously, cumbersome paper registers were required, along with tedious manual data aggregation procedures, requiring CHOs to spend copious amounts of time recording patient visits and registering insurance forms. Ghana’s efforts to expand access to its health insurance program only added to the information burden. A GEHIP baseline time-use study found that workers spent more time on paperwork than client care  and receDistrict health management teams require strengthened capabilities to make community-based care happen. These capabilities include management functions that foster community liaison and social mobilization, grassroots political engagement, volunteerism, gender-based communication, male outreach, etc. The GEHIP initiative aims to develop, test, and disseminate this package.Budgeting and resource mobilization has also been missing in the CHPS implementation experience. Indeed, when managers are interviewed about the reasons for the failure of CHPS to scale- up, the most widely cited problem concerns resource constraints and lack of feasible strategies for solving the resource mobilization challenge. While budget lines exist for activities that frontline workers can implement, the cost of launching CHPS services, particularly developing practical means for DHMT to raise support for the construction of health posts where workers can live and work, has no GHS budget line. Therefore, this has been a key focus of the GEHIP program.The GEHIP team entered into a partnership with counterparts in Tanzania who developed a project that combined a budgeting tool and an additional dollar per capita per year for five years. District managers were then able to use the tool to estimate the burden of disease (BoD) implications of investing that dollar in different programs. Research showed that this strategy enhanced the effective allocation of resources. With technical support from the Tanzanian PHIT Partnership team, their “PlanRep Toolkit” was re-engineered for trial by GEHIP as the District Health Planning and Reporting Toolkit (DiHPART). The implementation of DiHPART was designed to address the absence of a budget line for CHPS and the rational spending of health resources by districts. DiHPART enables district managers to allocate budget priorities according to their relative impact on the burden of disease. GEHIP also adds $0.85 per capita to district budgets per project year for DiHPART-guided programming.GEHIP has also used DiHPART to conduct broader training sessions with district and sub-district officials. Shortages in trained leadership for district operations, especially in the areas of planning, implementation, and community engagement are undermining Ghana’s efforts to strengthen its health system and foster CHPS expansion. Figure As Figure DiHPART has also become a tool for demonstrating the value of district development investment in CHPS. Prior to DiHPART, district managers lacked revenue for starting CHPS operations and practical tools for interacting with local politicians and development officers who had control of development resources for bridging funding gaps. The toolkit helped GEHIP district teams interact with counterparts with simple to understand visual diagrams of the value of health investment. The combination of leadership demonstration activities, community interaction, and DiHPART demonstrate the value of CHPS on scale-up in the three project districts, as Figure Both quantitative and qualitative research methodologies will be used to evaluate the impact of GEHIP.To adequately power the sample for unbiased estimates of posited changes in child survival, it is estimated that a total sample size of 5,741 women is required. However, assuming response/attrition of 10%, GEHIP increased the planned sample size to 6,300 respondents to ensure an adequate analysis base despite possible sample loss. GEHIP controls for baseline differences in background characteristics with “difference-in-differences” estimates of program impact  as the at refers to measurements of health outcomes at baseline, t′ refers to measurements of health outcomes at the end of the project, G indexes GEHIP localities, and C indexes comparison localities.Y describes a health outcome such as the under-5 mortality rate or another of the indicators appearing in Table Data from the household surveys on health status can be linked to facility data and health system readiness checklists to allow the project to determine whether changes in health outcomes are attributable to health systems processes. Multilevel hazard models of under-5 survival in the 60 sample GEHIP clusters will permit estimation of the effect of health system strengthing on child survival, adjusting for the potentially confounding effects of household characteristics.If GEHIP replicates the full effect of the Navrongo model, then its success in scaling up CHPS will reduce childhood mortality by half in three years.A limitation of the impact evaluation strategy is the timing of the endline survey, scheduled for mid-2014. To gauge the full impact of the Figure The quality of administrative data and HMIS may be improved by GEHIP activities, resulting in spurious changes in health systems indicators in intervention districts relative to comparison districts. For example, drug shortages may appear to be more common in intervention areas not because they are actually increasing but because facilities in intervention areas are better equipped to report such shortages. To account for this possibility, the project conducts recurrent facility surveys in intervention and comparison localities at all levels of care, including CHPS compounds.GEHIP monitors systems inputs and outputs and processes in intervention and non-intervention areas through administrative data collection, HMIS, qualitative appraisal, and facility-based surveys. The project will also rely on the CHPS monitoring database, a tool for documenting the national state of CHPS implementation.GEHIP has adapted procedures that were developed for the qualitative appraisal of CHPS implementation to the study of GEHIP implementation . Focus gActivities in both the intervention and non-intervention districts are occurring which the project lacks control. For instance, all three northern regions of Ghana are target districts for interventions by UNICEF and other donors. Since these priority interventions will take place in both treatment and comparison districts, donor priorities may contaminate the GEHIP intervention. GEHIP collects contextual information on external activities that may impact the primary outcomes of interest. Of particular significance is the recent parliamentary decision to split districts into smaller political units. At the onset of the project, there were nine functioning districts; by mid-2013 there will be 13. Data compiled from each sample cluster will include indicators of exposure to investments of external agencies and indicators of changes in political boundaries so that multilevel analyses can adjust for their potentially confounding effects and exposure to project interventions is appropriately attributed to sample survey clusters.Economic evaluation of the project will assess the unit cost associated with net health benefits that accrue from GEHIP expenditures. Cost and expenditure data are being gathered at each level of the system to allow for estimation of benefits resulting from supplementary expenditures in intervention districts. Efforts are directed to assessing external investment in regional programs, with particular attention to expenditures of UNICEF and other international agencies.Table The GHS PPME Division has committed to merge the simplified GEHIP registers with its new DHIMS-2 system and then scale the combined system up nationally, once technical problems with the existing tool are resolved.Implementation research has also been crucial to the process of scaling up. For example, problems arose during the piloting of the ambulance based emergency referral program described above. A bilateral donor provided Ghana with several hundred fuel efficient three-wheel “tri-cars,” several of which the GHS consigned to GEHIP for the pilot trial. However, tri-car ambulances designed for Asian urban conditions were highly unsuitable to the terrain of northern Ghana. Problems also arose during a trial of procedures for organizing and streamlining communication between remote health posts, sub-district health centers, and district hospitals using mobile phones. The study itself was successful but  advancedGEHIP has encountered other problems with DiHPART implementation. The tool assumes that “interventions” are grouped by disease syndromes or broad categories of activities that are complex, involving a wide range of investment options of varying degrees of efficacy or efficiency. IMCI, for example, is a complex array of community, clinical, and hospital-based activities. Disaggregating IMCI as a DiHPART parameter would assist DHMT in determining which IMCI investments make the most sense, given the resource environment. In revised form, DiHPART would visualize the burden of disease implications of more detailed health expenditure options.DiHPART implementation within districts has also proven to be challenging, owing to persistent staff turnover and hardware issues. Analysis of output from DiHPART has been compromised by software limitations, including its inability to provide for the management of actual cash flow. The lack of expenditure tracking capabilities impedes the administrative requirement of comparing actual spending to the planned budget. While district managers utilize DiHPART to plan activities, the system is not yet an accounting tool. As these issues are resolved, the tool is likely to be used at national and regional levels, enabling health plans to be based on scientific evidence and, therefore, more effective.In summary, GEHIP is a quasi-experimental study of a program designed to accelerate the scale- up of the Navrongo experiment — one of the most effective health development experiments conducted in Africa . GEHIP sBy focusing on community health activities alone and neglecting the larger political and development context, CHPS was unable to mobilize needed district leadership, budgeting, finance, and planning components. And, even where it went to scale, its impact was often impaired by the absence of capabilities to manage emergencies and save newborn lives. GEHIP aims to correct these problems with district systems strengthening activities and improving primary health care. Preliminary research results, illustrated in Figure BoD: Burden of Disease; CHO: Community health officer;CHPS: Community-based Health Planning and Services; DHIMS-2: District Health Information Management System; DHMT: District health management team; DiHPART: District Health Planning and Reporting Toolkit; DSS: Demographic Surveillance System; GEHIP: Ghana Essential Health Intervention Project; GHS: Ghana Health Service; HMIS: Health Management Information System; IHI: Ifakara Health Institute; IMCI: Integrated management of childhood illness; MSPH: Mailman School of Public Health; NGO: Non-governmental organization; NHRC: Navrongo Health Research Centre; PPME: Policy, Planning, Monitoring and Evaluation; RHA: Regional Health Administration; TEHIP: Tanzania Essential Health Interventions Project; UER: Upper East Region; UGSPH: University of Ghana School of Public Health.The authors declare that they have no competing interests.JA, AB, and JP participated in the design and coordination of the study and in the drafting of the manuscript. AB is the GEHIP Director of Research. FN directed the design and development of the DiHPART initiative and collaborated with AN in the write-up of the section of the paper on DiHPART. RA directs implementation activities and contributed to the implementation section of the manuscript. AO collaborates with JP and AB on research design and implemetnation issues. JP conceived of the study and participated in its design and coordination. All authors read and approved the final manuscript.


A web-based inventory was developed as a voluntary registry of Canadian pregnancy and birth cohort studies, with the objective to foster collaboration and sharing of research tools among cohort study groups as a means to enrich research in maternal and child health across Canada.Information on existing birth cohort studies conducted in Canada exclusively or as part of broader international initiatives was accessed by searching the literature in PubMed and PsychInfo databases. Additional studies were identified by enquiring about the research activities of researchers at Canadian universities or working in affiliated hospitals or research centres or institutes. Of the fifty-eight birth cohort studies initially identified, forty-six were incorporated into the inventory if they were of a retrospective and/or prospective longitudinal design and with a minimum of two phases of data collection, with the first period having occurred before, during, or shortly after pregnancy and had an initial study sample size of a minimum of 200 participants.Information collected from each study was organized into four main categories: basic information, data source and period of collection, exposures, and outcome measures and was coded and entered into an Excel spreadsheet. The information incorporated into the Excel spreadsheet was double checked, completed when necessary, and verified for completeness and accuracy by contacting the principal investigator or research coordinator. All data collected were then uploaded onto the website of the Institute of Human Development Child and Youth Health of the Canadian Institutes of Health Research. Subsequently, the database was updated and developed as an online searchable inventory on the website of the Maternal, Infant, Child and Youth Research Network.This inventory is unique, as it represents detailed information assembled for the first time on a large number of Canadian birth cohort studies. Such information provides a valuable resource for investigators in the planning stages of cohort studies and identifying current research gaps. Prospective longitudinal pregnancy or birth cohort studies exist in many countries to investigate the effect of prenatal, pregnancy, and early postnatal exposures and interventions on maternal health, pregnancy outcomes, and long-term child health, social adjustment, and adult chronic disease. Many such studies are designed to investigate the linkages between environmental and genetic factors and health and disease outcomes in both mother and child. The emergence of several birth cohort studies in Canada prompted two meetings in 2009 that fostered interaction among researchers conducting such studies. The Workshop of the Canadian Birth Cohort Research Network sponsored by the Maternal, Infant, Child and Youth Research Network (MICYRN) had the objective to develop linkages between the existing Canadian birth cohort studies to facilitate interactions and improve the potential for research collaborations . The WorSubsequent to these initial meetings, plans were formulated through a partnership between MICYRN, CIHR-IHDCYH and the Strategic Knowledge Cluster on Early Childhood Development (SKC-ECD) to plan and further develop the inventory of seventeen identified birth cohort studies that participated in the MICYRN workshop. Such birth cohort inventories exist in Europe . The iniThe search strategy was not that of a systematic review. Two search strategies were used to identify birth cohort studies conducted in Canada exclusively or as part of broader international initiatives. The first strategy was a keyword search of the existing literature in the databases of PubMed and PsychInfo using various combinations of the following terms “Canada,” “birth cohort,” “follow up,” “longitudinal studies,” “birth,” “pregnancy,” “infant,” “newborn,” “child,” “maternal,” “prenatal,” “postnatal,” “health,” and “development.” Articles that provided detailed information on a birth cohort study and met the established inclusion criteria were carefully read. The second search strategy involved an enquiry about the research activities of research centers, institutes affiliated with Canadian universities or hospitals and researchers at Canadian universities, primarily in departments of obstetrics and gynecology, pediatrics, psychology, and epidemiology/community health.Studies were included in the inventory if they were of a retrospective and/or prospective longitudinal design, with a minimum of two phases of data collection. Cross-sectional studies with retrospective data related to pregnancy and birth were not included. The first period of data collection had to have occurred before, during, or shortly after pregnancy including data retrospectively collected. Studies that had early childhood (beyond birth) as the first period of data collection were excluded. However, longitudinal studies conducted among children were included when retrospective data on pregnancy or young infant were collected. The initial subject sample size had to be a minimum of 200 participants. Smaller sample sizes were only included for studies on populations experiencing specific medical conditions, such as in premature babies and on women experiencing depression during pregnancy. For the purpose of this project, no limitation was placed on the number of years participants were enrolled in the study.Information collected from each study was organized into four main categories: basic information, data source and period of collection, exposures, and outcome measures. Basic information included cohort study title, the principal investigator(s), lead institute(s), enrolment year, enrolment status of the study, study design, initial sample size of mothers, fathers and children, inclusion and exclusion criteria for participants, gestational age at enrolment, source population, coverage, expected duration of follow-up, sample size at each follow-up, and cohort website address.Data sources included administrative databases, questionnaires, and bio-genetic samples. Data collection periods were categorized into first, second, or third trimester of pregnancy, at birth, 0 to 6 months, 7–18 months, 19–60 months, or 5 or more years after birth. The bio-genetic samples collected included blood, urine, hair, and saliva from mothers, fathers, infants, and children. Samples of placenta, meconium, breast milk, umbilical cord and umbilical cord blood were also noted. Blood samples were indicated as serum, plasma, whole blood, red cells, or white cells.Exposures were subdivided into social environment , school environment, social policy, natural environment, indoor environment, and food quality.Outcomes were subdivided into birth, child, and maternal outcomes. For each of these categories, information was divided into the following subcategories: preterm birth; fetal growth; birth defects; severe neonatal morbidity; neonatal mortality; child growth; acute and chronic illness among children; neurocognitive development; children behavioural problems and mental illness; language development; pregnancy complications; mode of delivery; severe maternal morbidity; and maternal mental health.Information obtained from each study was coded when necessary and entered into an Excel spreadsheet. Specific variables were assigned to the status of a study  and source population ), “hospital-based,” “region-based,” “nation-based,” or “multi-national”). Whether the sample was (a) of convenience, (b) population-based but not necessarily representative, or (c) representative (corrected for biases using population weights) was not categorized. “Y” or “N,” designating “yes” or “no,” was attributed to the types and periods of data source collection, exposures, and outcomes studied. The validity and reliability of these studies have nonetheless not been evaluated.The information incorporated into the inventory was verified and validated by contacting the principal investigator or research coordinator by phone or email. A period of one month was allocated to the validation of information, after which a second email was sent to researchers who had not yet responded. In the fall of 2009, all data collected were uploaded on the website of IHDCYH .Data contained in the Excel spreadsheet were modified according to program established for on-line access. Data in the inventory were updated in August 2010 through contact with the principal investigators or research coordinators of the studies logged in the system.Profiles of cohort studies: Of the 58 pregnancy and birth cohort studies initially identified, 46 were validated and incorporated into the inventory. The majority of these studies are either ongoing or in development; only 11 had been completed at the time the inventory was created. In total, these 46 birth cohort studies involve over 950,000 mothers, 24,000 fathers, and 1 million children; 78% of the studies have an initial sample size greater than 1000 participants. To our knowledge, only two studies were conducted among participants from a previous cohort, both of which are included in the inventory. The Emigarde project [Data collection: Although certain studies had only one means to collect their data, several studies used more than one method. While 37% of birth cohort studies rely on administrative databases such as the Quebec Pregnancy Registry and the London Perinatal Database Retrospective, 87% of studies collect their data through questionnaires and 54% of studies include bio-genetic samples. The most common period for data collection with questionnaires was 0–6 months after birth (63%), and the most common period for collecting bio-genetic samples was at birth (34.8%)  Figure .The environmental exposures varied widely across studies Figure . Forty-fKey outcome measures included pregnancy complications (43 studies), severe maternal morbidity (30 studies), birth defects (31 studies), and neonatal morbidity/mortality (34 studies), neurocognitive development (26 studies), and behavioural problems and mental illness among children (27 studies).The types of bio-genetic samples collected at various intervals in pregnancy and infancy varied across studies Table . Umbilic. The inventory also represents an important tool to foster potential and eventual collaborations among researchers. Among the array of information available from this inventory is information about the possibility for sharing the biobank and for research collaboration. Interested researchers can explore the complete inventory to examine such possibilities.The web application online searchable inventory not only facilitates the search for information, but also the management of the inventory. Studies can be retrieved by selecting a particular type of biological sample, exposure, or outcome of interest. The search can be restricted by choosing a combination of measures under these three categories or by entering a keywordThe current online cohort inventory provides key information stemming from 46 pregnancy and birth cohort studies that have incorporated a large number of subjects studied across diverse geographical locations in Canada. Types of exposures, outcomes, and biological samples are the key information elements available in the inventory. While nearly one million mothers and their offspring have been recruited in total across the 46 studies, not all subjects would be available for future contact. However, for studies still ongoing, re-consent might be possible if additional follow-up was desirable.3G), which supports the development and harmonization of epidemiological projects in genomics [This inventory is unique, as it represents detailed information assembled for the first time on a large range of Canadian birth cohort studies. As well, the content and format is aligned with inventories from Europe  and othegenomics . This alThe inventory also reveals major gaps in research. While most studies have collected data on the social environment of participants, data on the natural and indoor environment has been infrequently assessed. Despite the geographical coverage of studies extending across Canada, most are from Ontario or Quebec, and few include populations from the Eastern provinces or the Territories. In addition, few studies had immediate plans for genetic analysis, although some indicated banking of biological samples for possible future analysis.Output from the cohort workshops clearly identified the sharing of research tools as a key element that might be accommodated in future development of the online inventory. To evaluate that potential, we conducted a literature search of selected studies represented in the current inventory to determine the extent to which measurement tools currently employed were consistent across studies. This was accomplished by reviewing papers published by the cohorts that cited the measurement tools used. Researchers have drawn upon an array of scales, tests, and assessments to measure health outcomes Table . The chiThe selected review of measurement tools employed in the cohort studies included in the inventory revealed some consistency for measures of infant and child neurocognitive, education and social skills and of maternal depression. Clearly, there is great opportunity for sharing of other validated tools, such as quantitative assessment of dietary intake, physical activity, or relevant environmental influences.The current inventory represents only a first step. MICYRN and its partners, including the SKC-ECD will update and expand the inventory. Future expansion could include a repository for measurement tools, such as questionnaires and analytical methods, which could be shared with other studies and available upon registration in the MICYRN Birth Cohort Inventory. Such collaborations could improve validity and quality assurance of measurement tools. Finally, linkage of birth cohort databases to health care and other databases could also be facilitated by MICYRN to provide expanded opportunities for in-depth analysis.http://www.micyrn.ca/Networks.asp#2. The inventory can be searched at http://www.micyrn.ca/databases/cohortsearch.asp by type of Biological Samples, Exposures or Outcomes, and by Keyword. There is a link to a spreadsheet view of the complete inventory and a more detailed view of all data being collected in the complete inventory. Researchers are welcome to contribute to the development of the inventory by registering their cohort study, which meet our criteria of inclusion, at the following link http://www.micyrn.ca/databases/asplogin/CohortLogin.asp#2. Submitted forms return to the MICYRN Secretariat and are reviewed prior to entry into the Inventory to ensure they meet the original criteria set for study selection as described in the Background. Future expansion of the inventory will include an international scope.The online inventory is publically available and can be accessed at 3G: Public Population Project in Genomics.MICYRN: Maternal, Infant, Child and Youth Research Network; IHDCYH: Institute of Human Development, Child and Youth Health; CIHR: Canadian Institutes of Health Research; SKC-ECD: Strategic Knowledge Cluster on Early Childhood Development; PThe authors declare that they have no competing interests.SA initiated the pregnancy and Canadian birth cohort network and inventory and was responsible for the development of the manuscript and oversight of its completion and submission. AB was co-initiator of cohort network and reviewed the manuscript. MB contributed to the development of the inventory and reviewed the manuscript. M-P J conducted the literature search to identify the expanded cohort database and contributed to the establishment of the inventory within the Canadian Institutes for Health Research (CIHR) Institute of Human Development, Child and Youth Health (IHDCYH) and took a primary role in the writing and revisions of the manuscript. AJ facilitated the establishment of the online searchable inventory on the website of the Maternal, Infant, Child and Youth Research Network and reviewed the manuscript. MK facilitated the development of the inventory as a project within the CIHR IHDCYH. All authors read and approved the final manuscript.M-P J contributed initially to this project when a study analyst for the Institute of Human Development, Child and Youth Health at the Canadian Institutes of Child Health in Ottawa, Canada. She is currently a PhD student in the department of sociology at the University of Toronto.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/12/117/prepub


Ensuring high quality care for persons with diabetes remains a challenge for healthcare systems globally with consistent evidence of suboptimal care and outcomes. There is increasing interest in quality improvement strategies to improve diabetes management as reflected by a growing number of systematic reviews. These reviews are of varying quality and dispersed across many sources. In this paper, we present an overview of systematic reviews evaluating the impact of interventions to improve the quality of diabetes care.We searched for systematic reviews evaluating the effectiveness of any intervention intended to improve intermediate patient outcomes and process of care measures for patients with any type of diabetes. Two reviewers independently screened search results, appraised each systematic review using AMSTAR and extracted data from high quality reviews (AMSTAR score ≥ 5). Within reviews, we used vote counting by direction of effect to report the number of studies favouring an intervention for each outcome. We produced summaries of results for each intervention category.We identified 125 reviews of varying methodological quality and summarised key findings from 50 high quality reviews. We categorised reviews by quality improvement intervention. Eight reviews were broad based (involving a variety of strategies). Other reviews considered: patient education and support (n = 21), telemedicine (n = 10), provider role changes (n = 7), and organisational changes (n = 4). Reviews reported intermediate patient outcomes (e.g. glycaemic control) (n = 49) and process of care outcomes (n = 9). There was evidence of considerable overlap of included studies between reviews.There is consistent evidence from high quality systematic reviews that patient education and support, provider role changes, and telemedicine are associated with improvements in glycaemic and vascular risk factor control in patients. There is less evidence about the impact of quality improvement interventions on other key process measures such as screening patients for diabetic complications. This paper provides decision makers with a comprehensive overview of evidence from high quality systematic reviews about the effects of quality improvement interventions on improving diabetes care. Diabetes is a complex health problem that results in significant morbidity and mortality and health care resource utilisation -3. With Recognising that gaps exist between best and actual care, researchers, people with diabetes, clinicians and decision makers have shown an increasing interest in quality improvement (QI) strategies to improve diabetes management . QualityThere is substantial evidence and consensus on what constitutes high quality diabetes care . DespiteThe current interest in QI interventions to improve diabetes care has led to a profusion of primary studies on diabetes that is overwhelming. Whilst systematic reviews partly address this problem of information overload, decision makers often find it difficult to reliably retrieve and keep up to date with the growing volume of published systematic reviews . In addiWe included systematic reviews that evaluated interventions to improve the quality of diabetes care and management in patients of any age, with any type of diabetes, in any setting compared to usual care or other intervention(s). We defined a systematic review as a synthesis of research evidence in which literature searches, inclusion criteria, and critical appraisal methods were explicitly described. We excluded primary studies, and systematic reviews that addressed multiple chronic diseases where it was not possible to isolate the effects of QI interventions on diabetes care.To be included, systematic reviews had to report effects on at least one intermediate patient outcome, (glycaemic control as measured by glycated haemoglobin (HbA1c) level. vascular risk factor control as measured by high-density lipoprotein, total cholesterol, or blood pressure levels, or maintaining smoking cessation for at least one year) or process of care measure . We excluded systematic reviews that only reported changes in knowledge or attitudes towards treatment of diabetes .http://www.healthsystemsevidence.org/), Rx for Change (http://www.rxforchange.ca/), and Google.We searched the following electronic databases without language restrictions: Medline, EMBASE, AARP Ageline, AMED (Allied and Complementary Medicine), and HealthSTAR via OVID, The Cochrane Database of Systematic Reviews and DARE (Database of Abstracts and Reviews) via Wiley, Health Systems Evidence  checklist ,19, an 1Two reviewers independently extracted data from each included systematic review using standard forms developed for this overview. We used a consensus process to ensure the consistency and reliability of the data and enlisted the assistance of a third party in cases of disagreement. For each included systematic review, we extracted review level information on the objectives, publication year, number of included studies, search dates, country of origin, method(s) of analysis used, as well as relevant quantitative data such as pooled effect sizes. We did not retrieve primary study publications; rather we abstracted primary study data reported within each systematic review on study design, population, intervention(s), comparator, and direction of effect, whether reported descriptively or numerically. We classified the interventions used in each study using the McMaster Health Forum taxonomy .At the review level, we categorized each systematic review by quality improvement category ; providing a list of the characteristics of included studies (49/50); using appropriate methods to combine the findings of the included studies (48/50); assessing and documenting the scientific quality of included studies (47/50), and using the results of the scientific quality assessment in formulating conclusions (38/50). However fewer studies met AMSTAR criteria relating to the following: using independent reviewers for selecting studies and extracting data 29/50); using publication status as part of the inclusion criteria (25/50); assessing the likelihood of publication bias (22/50); providing an a priori design (21/50), and providing a list of the included and excluded studies (18/50). Only one review met the criteria for reporting conflict of interest of review and studies  and process of care behaviours (HbA1c and retinopathy monitoring) with mixed results for blood pressure control. Based on our assessment of 42 high quality intervention specific reviews, patient education and support interventions were shown to improve HbA1c, blood pressure, cholesterol, and diabetic foot outcomes in patients; telemedicine interventions were associated with improved glycaemic control in patients, and provider role change interventions improved glycaemic and vascular risk factor control in patients. It was unclear what impact organisational interventions had on glycaemic control in patients. It was also unclear if there was a relationship between the above four interventions and improvements in monitoring of HbA1c, vascular risk factors, or retinopathy, or diabetic foot outcomes. The majority of reviews only included randomised trials alone . In general, the results and conclusions of the systematic reviews that only included RCTs with or without CCTs were similar to those including a broader range of designs. We were unable to identify any high quality reviews that focussed on other QI interventions relevant to our objectives, such as financial or regulatory interventions.Our objective was to synthesise a comprehensive body of published evidence in a single overview. This is a challenging undertaking considering that overview methods are still evolving and a variety of approaches are being used ,76,77. SHowever, overviews inevitably suffer from potential weaknesses, some of which are common to all synthesis projects and others that are specific to overviews. Potential weaknesses that are common to all syntheses include the possibility that our searches missed relevant reviews, or that errors were made during study selection, quality appraisal and data collection. Overview-specific weaknesses relate to the fact that our unit of study is a completed systematic review. Thus, overview authors are dependent upon the methods of the included systematic reviews that potentially suffer from some of the common weaknesses mentioned above. Overviews that consider multiple reviews on the same topic potentially protect against weaknesses in individual reviews unless all included reviews share precisely the same methodological weakness. In our overview we also tried to minimise the likelihood that we would be misled by individual reviews by excluding low quality reviews that are more likely to suffer to from major methodological weaknesses.Overviews are also dependent on the reporting of the included systematic reviews, which limits the granularity of detail available to the overview author. As a result, the overview author needs to trust the systematic review authors' quality appraisal and data abstraction and is limited by the level of detail in the original systematic reviews when describing characteristics of included studies such as setting, and intervention, etcetera. As well, overviews are limited by the coverage of the identified systematic reviews. For instance, there has been increasing interest in the use of financial interventions to improve diabetes care; the United Kingdom introduced a pay-for-performance incentive program in 2004, rewarding family practices for achieving performance targets in chronic disease management, including diabetes . HoweverThe interventions examined in these reviews were frequently complex. Reporting of complex interventions is often poor in primary studies  and evenWithin our overview, we reanalysed the included reviews using vote counting based on direction of effect. The weaknesses of vote counting are well documented and include the failure to provide an estimate of the effect size of an intervention, failure to take into account the precision of the estimate from the primary comparisons, and giving equal weight to comparisons with 100 or 1,000 participants . NeverthOverviews are high-level syntheses of research evidence that provide an evidence map for decision makers and high-level conclusions about an issue. However, it is likely that decision makers will also need to consult some of the included systematic reviews, and potentially the individual studies, to address their specific questions. Thus, this synthesis is best seen as an entry point to evidence to inform healthcare decision makers' policy options about interventions to improve diabetes outcomes. Current initiatives to improve diabetes management and care should be informed by this evidence base. There is consistent evidence that a number of interventions, for example, patient education and support, telemedicine, and provider role changes, appear to improve diabetes quality of care, and policy-makers need to consider whether their current services optimally provide these effective interventions to their population of persons with diabetes. Overall, there is some evidence to suggest that tailoring interventions to specific cultural or age groups may be beneficial to the effectiveness of the treatment strategy. Interventions at an organisational level had insufficient evidence from which to draw conclusions about their effectiveness, and therefore policy makers should be cautious about implementing these approaches until further evidence is available.There is a considerable body of evidence evaluating interventions to improve diabetes care that should inform future research. Researchers conducting both primary studies and systematic reviews of diabetes quality improvement interventions should consider the breadth of outcomes relevant to excellent diabetes care. In areas with a substantial number of trials demonstrating benefit, for instance, patient education and support, future research should focus on direct comparisons of different delivery methods for the same intervention or of direct comparisons of the relative effectiveness of different interventions.The results of available systematic reviews should inform the choice and design of evaluated interventions and evaluative methods. For example, new systematic reviews of diabetes QI interventions might focus on interventions where there are few or no current systematic reviews. Patient education provides an example of a group of interventions where the depth and quality of the evidence is abundant and where further reviews may add little to our knowledge unless they address secondary questions such as how to optimise or extend the reach of patient education and support interventions. While we identified some evidence of attempts by researchers to separate the effects of complex interventions, future studies should further focus on such separation in order to provide specific advice on how to optimise efforts to improve diabetes management. Given our observation that 60% of the reviews assessed for this project were rejected based on low AMSTAR scores, researchers are strongly encouraged to consider AMSTAR assessment criteria during the systematic reviewing process in order to improve the methodological quality and/or reporting of their work.Overviews provide high-level summaries of empirical research. This overview identified and summarised the best current available evidence from 125 systematic reviews on the effectiveness of different QI interventions to improve diabetes care. The results suggest that patient education and support, provider role changes and telemedicine are associated with improved patient outcomes. They can be used by decision makers to identify policy options to improve diabetes care and as a source document to identify systematic reviews and individual studies that are relevant to their context and that address their specific questions. It also identified potential areas for future research; highlighting the problem of (likely) inappropriate duplication of effort between existing systematic reviews and the lack of high-quality systematic reviews addressing interventions of policy interest, such as regulatory or financial interventions.AMED: Allied and Complementary Medicine; AMSTAR: Assessment of multiple systematic reviews; CCT: Controlled clinical trials; DARE: Database of Abstracts and Reviews; EPOC: Effective Practice and Organisation of Care; HbA1c: Glycated haemoglobin; PRISMA: Preferred reporting items for systematic reviews and meta-analyse; QI: Quality improvement; RCT: Randomised controlled trial; SMS: Short message system.The authors declare that they have no competing interests. JMG is an author on one of the included reviews.JMG, AM and MCW conceptualised the project. MF developed and executed the search strategy. JW, SCW, RB, AM, MCW and JMG screened articles for potential inclusion. JW, SCW, RB, AM and MCW appraised the quality of articles. JW, SCW, RB, AM, KJS and MCW extracted data from the included reviews. JMG, JW, SCW, KJS and MF drafted and revised the manuscript. RB, JW, KJS prepared the tables and figures. All authors had full access to all data, contributed to revision of the manuscript and approved the final version. JMG is the guarantor. All members of the Diabetes QI Overview Team provided additional support and/or carried out specific project-related tasks. All authors read and approved the final manuscript.JMG holds a Canada Research Chair in Health Knowledge Transfer and Uptake.Search strategies. The full search strategies used in the evidence search.Click here for fileIntervention categories identified. Description of the intervention categories used to classify reviews.Click here for fileDetails of included reviews. Characteristics and results of the included reviews.Click here for fileList of excluded reviews. Bibliography of excluded reviews (reviews that scored less than 5 using AMSTAR tool).Click here for file


This study assessed the value of technical assistance provided by state health department expert advisors and by the staff of the National Association of Chronic Disease Directors (NACDD) to community groups that participated in the Action Communities for Health, Innovation, and Environmental Change (ACHIEVE) Program, a CDC-funded health promotion program.We analyzed quantitative and qualitative data reported by community project coordinators to assess the nature and value of technical assistance provided by expert advisors and NACDD staff and the usefulness of ACHIEVE resources in the development and implementation of community action plans. A grounded theory approach was used to analyze and categorize phrases in text data provided by community coordinators. Open coding placed conceptual labels on text phrases. Frequency distributions of the quantitative data are described and discussed.The most valuable technical assistance and program support resources were those determined to be in the interpersonal domain . The most valuable technical assistance events were action institutes, coaches’ meetings, webinars, and technical assistance conference calls.This analysis suggests that ACHIEVE communities valued the management and training assistance provided by expert advisors and NACDD staff. State health department expert advisors provided technical guidance and support, including such skills or knowledge-based services as best-practice strategies, review and discussion of community assessment data, sustainability planning, and identification of possible funding opportunities. NACDD staff led development and implementation of technical assistance events. Action Communities for Health, Innovation, and Environmental Change (ACHIEVE), a federally funded community health promotion initiative, used a collaborative development model to help communities prevent chronic diseases and decrease related risk factors. ACHIEVE was a partnership between local community organizations and national and state organizations whose goal was to create healthy, sustained communities where access to physical activity and healthful foods is high and exposure to tobacco is minimized. ACHIEVE educated and provided technical assistance to community leaders from various health-related or interested organizations on local policy and system and environmental improvements. We used reports submitted by ACHIEVE coaches (the community project coordinators) to analyze the types and value of the technical assistance and support provided by state health department expert and other resources available to ACHIEVE communities, as reported by 33 community project coordinators from 2008 through 2010.The National Association of Chronic Disease Directors (NACDD) was 1 of 5 national lead organizations that participated in offering technical assistance to additional ACHIEVE communities , worksites and businesses, government entities, local organizations and foundations, media, and community planners. These representatives engaged their communities and set priorities for strategic action by developing community action plans (CAPs) to guide and direct their efforts. These plans gave each CHART a road map for building long-term goals (at least 3 years) and short-term objectives (1 year), and for planning activities on a timeline and with a lead partner. CAPs were dynamic documents that enabled adaptations to changes in local priorities, political will, and availability of resources and funding.State health departments participated in the funding application process with the lead community organization, indicating their commitment to providing sustained technical assistance with data analysis, coalition management, community assessment strategies, and program planning, implementation, and evaluation. Each state health department appointed an expert advisor who offered support and technical assistance to the CHART and coaches. Expert advisors frequently provided expanded support linking communities to other state health department resources and other program technical assistance for media training, funding opportunities, epidemiology, and evaluation support. Expert advisors attended and participated in CHART meetings, webinars, and other required community program components and acted as ex-officio members of the CHART. NACDD staff informed the state’s chronic disease director of emerging program support and resource needs that the expert advisors should fulfill.NACDD staff consultants provided ongoing support remotely throughout the project funding periods, facilitating technical assistance, providing direct consultation, and referring coaches to resources and content experts. They supported each CHART, helped sustain community activity for CHARTs that were no longer receiving ACHIEVE funding, and helped with the planning and delivery of technical assistance events such as webinars, coaches’ meetings, and action institutes. Throughout 3-year funding cycles, funded coalitions received technical assistance via emails, one-on-one phone calls, conference calls, Web-based support, and site visits. Each community had a primary point of contact with an NACDD consultant.Sustainability Planning Guide for Healthy Communities (Staff of the Centers for Disease Control and Prevention (CDC) provided funding, technical support, and guidance from the Healthy Communities Program of the Division of Community Health. They used tools such as the munities  to assisDuring the first year of ACHIEVE funding, representatives of community coalitions attended 2 in-person coaches’ meetings and action institutes. The meetings included presentations and interactive exercises conducted by nationally recognized experts. These experts provided training and skill-building sessions and tools to assist community coalition members in implementing policy, systems, and environmental change strategies; building effective coalitions; and conducting community assessments.All ACHIEVE community coaches were provided opportunities to participate in groups called peer learning networks devoted to the process or focus area  they were working through. These groups had frequent conference calls during which they learned from each other. These interactive community networks were established at national meetings to share program successes and barriers to program development.In 2010, an online, 6-part social media training component was implemented. Multiple communication platforms including Facebook, Twitter, LinkedIn, YouTube, and Flickr were included. All ACHIEVE communities attended technical assistance and training webinars every 2 months throughout each 3-year contract. Topics included community assessment, evaluation, and community education strategies. Each CHART had access to a private portal that was a secured, password-protected website that allowed them to share program documents, post and access events on a common calendar, manage task lists, and, on a Web forum feature, discuss issues with national partners and community members.We reviewed quantitative and qualitative content reported by community project coordinators on the nature and value of technical assistance provided by expert advisors and NACDD staff and the usefulness of ACHIEVE resources in the development and implementation of community action plans. The quantitative data presented is a compilation of data reported by ACHIEVE local project coordinators in semiannual reports. Because these data included information from 3 separate cohorts , it is aggregated across the 3 years of reporting. The 2008 cohort of communities included 3 years of reports ; the 2009 cohort included 2 years of reports (startup and second year of funding); and the 2010 cohort included 1 year of reports (the startup year). The quantitative variables were selected because they were consistently reported across all 3 NACDD-managed cohorts (2008–2010). ACHIEVE community project coordinators were asked to select responses from a multiple-choice question that asked, “How has your State Expert Advisor been involved in your ACHIEVE activities during the current progress reporting period?” Because semiannual reporting took place over a 3-year period and multiple responses to questions were offered, the frequency with which responses were selected was low. Not all response options were included in the questions during the 3 years of reporting. If the number of respondents is below 61 , the queOne of the quantitative variables reported also included qualitative text information: How were expert advisors involved in ACHIEVE activities? The text data (“other” responses) were analyzed using a grounded theory approach  to enricWe asked for responses to questions that asked how expert advisors were involved in ACHIEVE activities . The mosSeventeen of the 25 “other” comments (68%) were positive, and the remaining 8 (32%) were neutral. Some of the positive comments were:. . . we just got a new expert advisor this month. So far, she has been amazing!In coordination with our City Planner, the expert advisors provided a Complete Streets presentation to the City Planning Commission.[The expert advisors] looked for funding opportunities within the state.[Name] was a great sounding board for ideas and thinking processes through.The neutral comments were observations on the ACHIEVE process, staff turnover, or observations not based on the work of the expert advisors. Some examples of those comments were the following:Our original expert advisor got a promotion and is no longer working with ACHIEVE.Our previous state expert advisor left in December.Our expert advisor provided GoTo Meeting software and technical support to be able to hold CHART meetings and webinars for those unable to travel. . . .Three of the 25 “other” comments about state expert advisors involvement (12%) were negative .Five out of 6  coaches helped collect or analyze community needs assessment data, and 82% (n = 37) reviewed the CAP . Other cIn addition, resources outside of ACHIEVE communities  contributed to the development of the CAP . CHART mNACDD staff made contributions similar to those made by state health department staff with review of the CAP  and collection and analysis of assessment data  being the most frequently mentioned contributions. Drafting of the CAP , discussion of assessment data , and presentation of assessment data to CHART or community  were the next most frequent. The most commonly selected contribution from CDC staff was collection and analysis of assessment data with 11.1% of responses (n = 5) indicating this contribution. This low percentage was not unexpected because CDC staff did not have a primary role in providing technical assistance and community project support.Community coaches reported the helpfulness of technical assistance resources with each report. Coaches meetings were rated as a leading resource in the “very helpful” category . Three-fourths  of the community coaches rated action institutes as a very helpful resource, followed by the technical assistance provided by NACDD  and the state health department expert advisors . The next most helpful resources were webinars and technical assistance conference calls , site visits by NACDD staff , peer-to-peer support , and State Healthy Communities Coordinators .State expert advisors were most active in providing technical assistance by identifying best practices and advising ACHIEVE CHARTs on policy, system, and environmental change strategies. This technical assistance supplemented the technical assistance and training that all CHART members received while attending training offerings. Expert advisors assisted communities in understanding and prioritizing assessment data, action planning and implementation, finding ongoing funding to sustain activity, and linking with other healthy community programs.Because state expert advisors may also have had a broad responsibility to serve other communities in their state, it was perhaps consistent with their job responsibilities that they identified and shared best practices on developing policy, system, and environmental strategies to agencies not funded by ACHIEVE and used local strategies to inform state policies. The low percentage of “no state expert advisor involvement” reported by community coaches suggests that these public health professionals were widely engaged in providing technical assistance. The content of the qualitative text or other data reported supports the high level of active engagement of the expert advisors in ACHIEVE community activity. The analysis of the write-in responses suggests that, at minimum, expert advisors were welcomed by local ACHIEVE coaches, helped present best-practice strategies to community leadership, helped identify funding opportunities for ACHIEVE coalitions, and were responsive to ideas and proposed processes suggested by community coalition members.Expert advisors were also engaged in the more technical aspects of community coalition activity . Expert advisors may have preferred providing this type of support and coaches frequently acknowledged this support, or both. Expert advisors support that was more technical in nature may have been motivated, at least in part, by the job descriptions at the state health agency, professional interests, or formal training of the expert advisors. Because many community coalition members had no formal public health training, expert advisors may also have recognized a need for a higher level of technical assistance.The data suggest that coaches made the most significant contributions to the development of CAPs across all communities. Because response frequency for contributions to the development of CAPs for the CHART executive team was comparable to that of other CHART members across all response categories, a broad, cross-section of CHART membership may have contributed at least as much as the executive team. This further suggests that ACHIEVE communities were characterized by their broad, grass-roots community participation. Other national ACHIEVE lead organizations and CDC staff were not expected to provide technical assistance and support to NACDD’s ACHIEVE communities. Consequently, community coordinators reported that these organizations contributed minimal support for the development of NACDD’s ACHIEVE teams community action plans.The most helpful technical assistance and program support resources to ACHIEVE communities were those provided through interpersonal communications. Face-to-face technical assistance provided by the state expert advisors, NACDD staff, and peer-to-peer interactions was most valued. Other helpful technical assistance events, which also had interpersonal, interactive elements, were the webinars and technical assistance conference calls, the action institutes, and coaches’ meetings.State health department expert advisors tended to provide technical guidance, including such skills- or knowledge-based services as assistance with best-practice strategies, review and discussion of community assessment data, sustainability planning, and identification of possible funding opportunities. Although regular or day-to-day support provided by expert advisors and NACDD staff may have been valuable for community coordinators (coaches) and their communities, events such as the coaches’ meetings, action institutes, and webinars were complementary learning opportunities that provided intensive, interactive training and education for community coalition members both off- and on-site. These learning events enabled trainers and trainees to ask each other challenging questions. This analysis of community ACHIEVE coach-reported data suggests that community coalitions that engaged in policy, system, and environmental change strategies benefitted greatly from a comprehensive, diverse portfolio of technical assistance and support strategies.


Approximately 90% of Americans aged 2 years or older consume too much sodium . The conLocal efforts can improve local nutrition environments  and infoEnvironment influences food choice and behavior ,4,5, andIn September 2010, CDC awarded 6 communities  funding The strategies can be grouped into 4 general approaches: 1) procurement, 2) reformulation, 3) product placement, and 4) consumer awareness. These strategies are not mutually exclusive, and communities are finding that a combination of strategies is often most effective.Organizations that purchase and provide meals — such as local and state governments, programs that provide foods to citizens, private businesses, schools, hospitals, and other institutions — can influence the food environment by adopting policies that require that the food they purchase, provide, or make available contains key nutrients at levels that meet standards and that adhere to dietary guidelines . In an eIn the absence of a city- or county-level policy, local health departments and other government and nongovernment agencies can incorporate contractual stipulations to increase the healthfulness of foods and model more healthful food environments. Broome County, New York, issued a request for proposals for vending equipment and services that included nutritional requirements for foods and beverages sold in county government buildings .Another purchasing action to reduce sodium intake is to increase buying power by combining resources. Schenectady County, New York, is forging partnerships with local independent restaurant owners and the founder of a restaurant cooperative to assess the effectiveness of leveraging multiple buyers to increase demand for lower-sodium ingredients. Shasta County is working with multiple school districts to increase participation in a local cooperative to leverage buying power to increase demand and affordability of lower-sodium items.Because most of the sodium Americans consume is found in restaurant and processed food , severalCommunities are working in retail settings to make changes in product placement to make healthful choices more easily identifiable and accessible. New York City is working with hospitals to promote healthful food and sodium reduction by developing and implementing hospital retail standards, which include standards for food items as well as product promotion, placement, and portion size . ShawneeIncreasing consumer awareness is vital for increasing demand for greater choice and for ensuring successful sodium-reduction strategies . ConsumeReadily available information about the nutritional content of foods can assist consumers in making more healthful choices, and communities can implement innovative strategies for providing this information. Shasta County is working with independent restaurants to implement a restaurant recognition program that allows participating restaurants to identify menu items that meet defined nutritional standards, including those related to sodium, at the point of purchase .A key component of SRCP is evaluating the effectiveness of strategies being implemented. The evaluation consists of a 3-year cross-site process and outcome case study for each community by an outside evaluator and a local evaluation conducted by each community; results will be available in 2013. As communities conduct evaluation to build the evidence base around sodium reduction strategies, early results indicate that communities are making progress toward meeting SRCP’s short-term outcome of facilitating environmental changes that increase availability of and access to lower sodium foods and the long-term goal of reducing sodium intake to recommended limits. Communities can lead in adopting population-level approaches to reducing sodium consumption, a key strategy for reducing blood pressure levels. The SRCP supports communities in implementing and evaluating strategies related to food procurement, food reformulation, placement strategies, and consumer awareness. This work will provide insight into community-level strategies that can successfully create more healthful food environments and reduce sodium consumption, contributing to the larger goal of reducing cardiovascular disease.


Little is known about the ground-dwelling arthropod diversity in tropical montane cloud forests (TMCF). Due to unique habitat conditions in TMCFs with continuously wet substrates and a waterlogged forest floor along with the innate biases of the pitfall trap, Berlese funnel and Winkler extractor are certain to make it difficult to choose the most appropriate method to sample the ground-dwelling arthropods in TMCFs. Among the three methods, the Winkler extractor was the most efficient method for quantitative data and pitfall trapping for qualitative data for most groups. Inclusion of floatation method as a complementary method along with the Winkler extractor would enable a comprehensive quantitative survey of ground-dwelling arthropods. Pitfall trapping is essential for both quantitative and qualitative sampling of Diplopoda, Opiliones, Orthoptera, and Diptera. The Winkler extractor was the best quantitative method for Psocoptera, Araneae, Isopoda, and Formicidae; and the Berlese funnel was best for Collembola and Chilopoda. For larval forms of different insect orders and the Acari, all the three methods were equally effective. Patches of tropical montane cloud forests (TMCF) occur in Central and South America, tropical Africa, and tropical Asia where humid mountains are frequently enveloped by tradewind-derived orographic clouds and fog in combination with convective rainfall . Many feConfinement of ground-dwelling arthropods of TMCFs to narrow altitudinal belts and their adaptations to exist in specific habitat conditions make these arthropods sensitive to habitat loss and fragmentation . BecauseSampling of arthropods from high-altitude, wet terrestrial habitats is always hindered by practical difficulties, especially when random and quantitative samples are necessary. In particular, the unique and inherent bias of every such sampling method either excludes or underestimates abundances of some groups and renders interpretations difficult. Behavioural differences among faunal elements and the characteristics of the habitat where sampling is to be done, strongly influence the sampling techniques . Unique Spatially and temporarily restricted densitybased quadrat sampling techniques (Berlese and Winkler extraction methods) may fail to capture many active groups . PitfallWhat are the relative trapping efficiencies of these three widely used trapping methods, measured in terms of abundance and frequency of occurrence of ground dwelling arthropods, to obtain baseline information as rapidly as possible?Which taxa are most likely collected in a baseline study using the three sampling methods?Which taxa are the best collected by specific-trapping methods?Our goal was to compare the efficiency of the pitfall trap, Berlese funnel and Winkler extractor in a TMCF in the Western Ghats, a global hotspot of biodiversity in south-western India, by seeking answers to the following questions:2; Idukki District, Kerala State)   , on the a State) . Patchesa State) . In souta State) . Annual 2 area, three patches named TMCF 1, TMCF 2, and TMCF 3 (each of 1–2 ha) on the east-facing hill slopes at 2200 m asl on the eastern side of ENP were selected for sampling. These TMCFs were at 500 m distance from each other. Three parallel 100 m line transects, separated by a 10 m inter-transect distances, were constructed west—easterly in each patch at a distance of 10 m from the forest edge. The mid-transect was used for pitfall traps and those on either side of the mid-transect were used for collecting litter samples (hereafter referred as litter sample collection locations) for Berlese and Winkler methods. A 25 m inter-trap distance between two consecutive pitfall traps and litter sample collection locations was maintained following Digweed et al.  over Ehrlen-Meyer flasks containing into 70% alcohol placed at the end of the funnel stems over five days.Winkler extractor. Litter samples were placed in coarse-mesh bags, which were suspended inside a large closed cloth bag suspended over a collection bottle 100 ml containing 50 ml of 75% ethanol  buried up to its rim in soil and partly filled with 50 ml of propylene glycol. Each trap was roofed over with a transparent sheet supported on iron pegs to prevent entry of rainwater and falling leaves and debris, which may facilitate escape of trapped fauna; such a system operated for 24 h continuously to avoid possible bias in captures arising from diurnal activity variation of fauna , and were identified up to superorder/order/family levels following Borror et al.  and by cThe frequency of occurrence and abundance of taxa in each trapping method was recorded. Frequency of occurrence means the frequency of collection (i.e. proportion of traps in which each taxon was found) and frequency of abundance means the total number of individuals of a particular taxon per sample in each trapping method. All determined specimens were deposited in the Entomological collections of St. Joseph's College, Devagiri, Calicut.Hymenopteran taxa other than Formicidae and Chalcidae are collectively referred as ‘Other Hymenoptera’. Taxa at >25% frequency in any of one of the sampling method was considered ‘major’, and those at <25% frequency were considered ‘minor’. The sampling method, which trapped >25% frequency of a particular taxon, was deemed ‘reasonably effective’ in sampling of that particular taxon.The sampling effort was calculated based on the time spent for field placement of traps and retrieval after 24 h for pitfall traps; for the Berlese and Winkler methods, collection of litter samples extraction and sorting of faunal groups was calculated during the pre-summer period. The pre-summer period was selected for cost estimation because in this period the highest ground dwelling arthropod abundance had been noted in the moist Western Ghats . The lenDifferences in the frequency of arthropod taxon among sampling methods  rendered comparisons through the application of common parametric statistics inappropriate. The Winkler extraction method emphasized seeking differences in the frequency of occurrence of arthropod types more and testing for differences in the mean number of arthropod types following Prasifka et al.  less. Hi2tests. Significant χ2 values indicated an effect of trap type on the proportion of samples containing one or more individuals of an arthropod taxon  or unsuccessful ; the differences were assessed with χod taxon . Trap—wiod taxon .Mean and standard deviation of the length of time required for sampling with each trap type were calculated. Trap—wise differences in the length of time needed to collect, extract, and sort samples were assessed with ANOVA, and when the differences were significant pairwise analyses were done with Tukey—Kramer test. All the analyses were done using MegaStat Version 10.0 .Altogether, fauna from 135 samples with 45 from each method were available for data analysis. From the three methods tested, 5275 individuals belonging to 24 arthropod taxa were collected. These arthropod taxa could be broadly divided into a major group of 12 taxa with > 25% of frequency in any one method and a minor group of 12 taxa with <25% of frequency . Based oThe proportionate distribution of dominant taxa in the collections from Winkler extractors was in the following sequence: Acari (78%) > Araneae (69%) = larvae of insects (69%) > Formicidae (49%) > Psocoptera (36%) > Coleoptera (30%). The highest frequency of occurrence was recorded for taxa belonging to Psocoptera and Formicidae, and an equivalent level of frequency of occurrence as those from the Berlese method for seven taxa: Orthoptera, Coleoptera, Diptera, other Hymenoptera, Chalcidae, larvae of insects, and Acari. A comparison of the captures from the Berlese and Winkler methods showed that the Berlese funnels recorded the highest frequency for Collembola and Chilopoda, whereas the Winkler extractors recorded the highestfrequency for Formicidae, Psocoptera, Isopoda, and Araneae .The dominance pattern of major taxa in Berlese extraction method was ‘Acari (89%) > larvae of insects (87%) > Collembola (58%) > Araneae (42%) > Coleoptera (37%)’. Berlese funnels recorded an equivalent level of frequency of occurrence as the Winkler extractors for seven taxa, and the same frequency of occurrence as that obtained in pitfall trap for Formicidae .Proportionate capture of the dominant taxa in pitfall trap was ‘Araneae (87%) > Diptera (84%) > Collembola (82%) > Acari (78%) > larvae of insects (67%) > Orthoptera (60%) > Coleoptera (43%)’. For the Collembola, Orthoptera, Coleoptera, Diptera, Hymenoptera, Araneae, Diplopoda, Isopoda, Chalcidae, and Opiliones, the pitfall trap yielded the highest frequency and for categories such as larvae of insects and Acari, a similar frequency as that obtained in the other two methods. Opiliones and Diplopoda were groups unique to the pitfall trap, and were recorded at a high frequency (with >50% more than what was recorded in the other two methods) in pitfall traps .In brief, pitfall traps recorded the highest frequency for 10 out of 13 taxa (eight major and two minor taxa), Winkler extractors for 2 out of 13 and Berlese funnels for none (0 out of 13). All three methods recorded same level of frequency of occurrence for the larvae of insects and Acari. Among the quadrat methods, Berlese funnels were effective for 7 out of 13 groups ; and the Winkler extractor was effective for 9 out of 13 groups  and Collembola and Chilopoda for which Berlese funnel is superior) .Abundance data for the ground-dwelling arthropods (median ± inter quartiles) in the three sampling methods have been summarized in Comparison of cost in terms of length of time required to sample  ground-dwelling arthropods showed significant differences among the three trap types . When thAll methods used for sampling grounddwelling arthropods in TMCFs produced biased data. Density-based quadrat estimators (Berlese and Winkler methods) sampled less of a few taxa, and the activity-based pitfall traps sampled less of a few groups and sampled more of many other groups. Among the three methods, Winkler method was most efficient for exhaustive quantitative data and the pitfall trap was most efficient for qualitative data of most ground-dwellingarthropods in TMCFs. Group and trap-specific differences noted in the present study supports the earlier findings  that no A pronounced difference occurred among the three tested sampling methods. Pitfall traps yielded the maximal capture (both frequency and abundance) of 12 out of 24 taxa, followed by the Winkler method for 02 out of 24 taxa, and the Berlese method for 0 out of 24 taxa; and for larvae of insects and Acari all the methods are equally effective. The Berlese method proved the least effective among the three methods for any taxa. Pitfall traps become indispensable for Diplopoda and Opiliones and for Orthoptera and Diptera with exceptionally high abundance and frequency of capture. These percentages (effective capture of 50% of the whole taxa) indicate that the pitfall trap is the most useful arthropod collection method for ecological studies of ground-dwelling arthropods, when compared with Berlese and Winkler methods. Non-significant differences in the capture of minor taxa (9 out of 24) among the different trap types are difficult to interpret because of their low frequency of occurrence and abundance possibly related to the low population densities of these taxa in the wet forests of the Western Ghats .However, a strong bias was apparent in the samples obtained with pitfall traps compared with the Berlese and Winkler methods. Pitfall trap traps captured more taxa of surface-active invertebrates: Orthoptera, Diptera, Araneae, Collembola, Coleoptera (with more of Staphylinidae), other Hymenoptera,Chilopoda, Diplopoda, and Opiliones  in compaIn addition to the above limitations, pitfall trap traps necessitated a second field visit to the high-altitude TMCFs to retrieve the traps involving additional expenditure, time loss, and practical difficulties in protected forests with restricted access. Moreover, multiple chances of wildlife disturbing the field-placed traps, and inclement weather, especially strong winds, affecting the sampling effort in TMCFs, also exist. Such a situation would generally leave the researcher in suspense on the success of the collection efforts until the second trip and would make collection of samples for pitfall trap more laborious, costly, and unreliable than Berlese and Winkler methods. Since extraction of fauna with Berlese/Winkler methods apparatus is a laboratory based, passive activity and the researcher could utilize the time usefully for other activities, it was considered reasonable in the present study to exclude the length of time taken for faunal extraction by the Berlese/Winkler methods from the overall sampling time and from comparative analysis of cost. When the time taken for extraction of fauna with Berlese/Winkler methods apparatus is excluded, pitfall traps become less efficient than Berlese/Winkler methods for overall sampling. By contrast, the pitfall trap has one clear advantage over the spatially and temporarily limited quadrat sampling methods (Berlese and Winkler methods) as it enables collection of nocturnal and diurnal guilds of taxa.This limits the choice of methods to two density based quadrat estimation methods (Berlese and Winkler methods). Recent studies in the moist deciduous forests of the Western Ghats showed that the Berlese method was a more efficient alternative method for exhaustive extraction of grounddwelling arthropods than Winkler extraction method . HoweverLower occurrence of Formicidae, Isopoda, Psocoptera, and Araneae using the Berlese method compared with the Winkler method could be due to the factors of heat and desiccation that are used for the Berlese method, which is a weakness in extracting fauna from moist forests . Ground—The presence of the two pitfall—trap unique groups, Opiliones and Diplopoda, and the low abundance of Orthoptera, Diptera, and Collembola indicate that use of the Winkler method alone will lead to underestimation of these taxa, thus leaving the researcher with two choices: (1) ignore the under-represented groups ; or (2) To summarize, the trapping success of pitfall traps confirms the findings of Spence and Memelä  that pitThe relative frequency of occurrence and abundance of fauna were different with each of the three sampling methods. When cost and time constraints dictate limiting of grounddwelling arthropod sampling to one method, the Winkler extraction method is ideal for quantitative estimation and the pitfall trap is ideal for qualitative estimates in TMCFs. The low incidence of five taxa: Orthoptera, Diptera, Opiliones, Araneae, and Diplopoda collected by the Winkler method necessitates inclusion of a complementary floatation method, which would enable a comprehensive quantitative survey of ground-dwelling arthropods. Although pitfall traps tend to collect more of the ground-active species, its efficiency indicates that the pitfall trap is certainly the method of choice for an individual qualitative sampling method for most major taxa except the Formicidae and Psocoptera. For Formicidae and Psocoptera, the Winkler method is the best option. As a cost-effective individual quantitative sampling method, the Berlese method is suitable for collecting larvae of insects, and Acari, and Chilopoda in TMCFs, but is not suitable for ecological studies involving multiple arthropod groups or for other taxa.