An epidemiologic evaluation of a worksite based intervention

The healthcare industry spends billions on worker injury and employee turnover. Hospitals and healthcare settings have one of the highest rates of lost days due to injuries. The occupational hazards for healthcare workers can be classified into biological, chemical, ergonomic, physical, organizational, and psychosocial. Therefore, interventions addressing a range of occupational health risks are needed to prevent injuries and reduce turnover and reduce costs. ^ The Sacred Vocation Program (SVP) seeks to change the content of work, i.e., the meaningfulness of work, to improve work environments. The SVP intervenes at both the individual and organizational level. First the SVP attempts to connect healthcare workers with meaning from their work through a series of 5 self-discovery group sessions. In a sixth session the graduates take an oath recommitting them to do their work as a vocation. Once motivated to connect with meaning in their work, a representative employee group meets in a second set of five meetings. This representative group suggests organizational changes to create a culture that supports employees in their calling. The employees present their plan in the twelfth session to management beginning a new phase in the existing dialogue between employees and management. ^ The SVP was implemented in a large Dallas hospital (almost 1000 licensed beds). The Baylor University Medical Center (BUMC) Pastoral Care department invited front-line caregivers (primarily Patient Care Assistants, PCAs, or Patient Care Technicians, PCTs) to participate in the SVP. Participants completed SVP questionnaires at the beginning and following SVP implementation. Following implementation, employer records were collected on injury, absence and turnover to further evaluate the program's effectiveness on metrics that are meaningful to managers in assessing organizational performance. This provided an opportunity to perform an epidemiological evaluation of the intervention using the two sources of information: employee self-reports and employer administrative data. ^ The ability to evaluate the effectiveness of the SVP on program outcomes could be limited by the strength of the measures used. An ordinal CFA performed on baseline SVP questionnaire measurements examined the construct validity and reliability of the SVP scales. Scales whose item-factor structure was confirmed in ordinal CFA were evaluated for their psychometric properties (i.e., reliability, mean, ceiling and floor effects). CFA supported the construct validity of six of the proposed scales: blocks to spirituality, meaning at work, work satisfaction, affective commitment, collaborative communication, and MHI-5. Five of the six scales confirmed had acceptable measures of reliability (all but MHI-5 had α>0.7). All six scales had a high percentage (>30%) of the scores at the ceiling. These findings supported the use of these items in the evaluation of change although strong ceiling effects may hinder discerning change. ^ Next, the confirmed SVP scales were used to evaluate whether the intervention improved program constructs. To evaluate the SVP a one group pretest-posttest design compared participants’ self-reports before and after the intervention. It was hypothesized that measurements of reduced blocks to spirituality (α = 0.76), meaning at work (α = 0.86), collaborative communication (α = 0.67) and SVP job tasks (α = 0.97) would improve following SVP implementation. The SVP job tasks scale was included even though it was not included in the ordinal CFA analysis due to a limited sample and high inter-item correlation. Changes in scaled measurements were assessed using multilevel linear regression methods. All post-intervention measurements increased (increases <0.28 points) but only reduced blocks to spirituality was statistically significant (0.22 points on a scale from 1 to 7, p < 0.05) after adjustment for covariates. Intensity of the intervention (stratifying on high participation units) strengthened effects; but were not statistically significant. The findings provide preliminary support for the hypothesis that meaning in work can be improved and, importantly, lend greater credence to any observed improvements in the outcomes. (Abstract shortened by UMI.)^

Effects of early and late lesion of orbital frontal cortex on visual processing of faces in rhesus macaques (Macaca mulatta)

Many mental disorders disrupt social skills, yet few studies have examined how the brain processes social information. Functional neuroimaging, neuroconnectivity and electrophysiological studies suggest that orbital frontal cortex plays important roles in social cognition, including the analysis of information from faces, which are important cues in social interactions. Studies in humans and non-human primates show that damage to orbital frontal cortex produces social behavior impairments, including abnormal aggression, but these studies have failed to determine whether damage to this area impairs face processing. In addition, it is not known whether damage early in life is more detrimental than damage in adulthood. This study examined whether orbital frontal cortex is necessary for the discrimination of face identity and facial expressions, and for appropriate behavioral responses to aggressive (threatening) facial expressions. Rhesus monkeys (Macaca mulatta) received selective lesions of orbital frontal cortex as newborns or adults. As adults, these animals were compared with sham-operated controls on their ability to discriminate between faces of individual monkeys and between different facial expressions of emotion. A passive visual paired-comparison task with standardized rhesus monkey face stimuli was designed and used to assess discrimination. In addition, looking behavior toward aggressive expressions was assessed and compared with that of normal control animals. The results showed that lesion of orbital frontal cortex (1) may impair discrimination between faces of individual monkeys, (2) does not impair facial expression discrimination, and (3) changes the amount of time spent looking at aggressive (threatening) facial expressions depending on the context. The effects of early and late lesions did not differ. Thus, orbital frontal cortex appears to be part of the neural circuitry for recognizing individuals and for modulating the response to aggression in faces, and the plasticity of the immature brain does not allow for recovery of these functions when the damage occurs early in life. This study opens new avenues for the assessment of rhesus monkey face processing and the neural basis of social cognition, and allows a better understanding of the nature of the neuropathology in patients with mental disorders that disrupt social behavior, such as autism. ^

A summative evaluation of a HIV/AIDS Early Childhood Care, Education and Development Teacher Training Workshop in Mongu, Zambia

Objective. To conduct a summative evaluation of an Early Childhood Care, Education and Development (ECCED) Teacher Training Workshop in Mongu, Zambia by assessing changes in knowledge, attitudes and intent to use the information. ^ Study design. A matched cohort survey design was used with additional qualitative data collected by structured observation of workshop sessions, daily facilitator and participant debriefs and participant interviews. ^ Results. Matching pre and post tests were completed by 27 individuals in addition to daily debriefs, structured workshop observation and participant interviews with 22% of the group. The participant population was predominantly female individuals aged 15-44 years old that had completed high school and additional post-secondary training, been teaching children aged 0 – 8 years for 2-5 years in the Western Province and received other HIV/AIDS and ECCED education. Pre-tests indicated a strong understanding of ECCED principles and misconceptions regarding HIV transmission, prevention and the disease's impact on early childhood development. The workshop was found to significantly increase the participants' knowledge of topics covered by the curriculum (paired t-test, N=27, p = 0.004, 95% CI 1.8, 8.6). Participants began with a more limited understanding of HIV/AIDS than ECCED, but the mean gain was much greater at 7.4 +/- 12.3 points. Significantly more participants believed at post-test that HIV/AIDS education should increase for future educators. The 77.8% of participants that increased their knowledge scores at post-test expressed significantly less fear of having a child with HIV/AIDS in the classroom (Independent Samples t-test, N= 27, p = 0.011). Overall participant fear decreased 15.5%. 92.6% and 88.9% of participants planned at post-test to respectively use and share the taught information in their daily professional lives and reported on innovative strategies to communicate with the community. ^ Conclusions. Teacher training workshops can significantly increase HIV/AIDS awareness and promote positive attitudes in educators working with children affected by HIV/AIDS. Using participant suggested teaching techniques such as poems and songs and translating the materials to the local language could assist future facilitators to both culturally and professionally relate to the workshop audience as well as increase participant capacity to share the information with the local community. ^

Early stage breast cancer and comorbidities: Their impact on breast cancer disease-free survival differences by ethnicity

The retrospective cohort study examined the association between the presence of comorbidities and breast cancer disease-free survival rates among racial/ethnic groups. The study population consisted of 2389 women with stage I and II invasive breast cancer who were diagnosed and treated at the M.D. Anderson Cancer Center between 1985 and 2000. It has been suggested that as the number of comorbidities increases, breast cancer mortality increases. It is known that African Americans and Hispanics are considered to be at a higher risk for comorbid conditions such as hypertension and diabetes compared to Caucasian women (23) (10). When compared to Caucasian women, African American women also have a higher breast cancer mortality rate (1). As a result, the study also examined whether comorbid conditions contribute to racial differences in breast cancer disease-free survival. Among the study population, 24% suffered from breast cancer recurrence, 6% died from breast cancer and 24% died from all causes. The mean age was 56 with 41% of the population being women between the ages of 40-55. One or more comorbidities were reported in 84 (36%) African Americans (OR 1.57; 95% CI 1.19-2.10), 58 (31%) Hispanics (OR 1.25; 95% CI 0.90-1.74) compared to the reference group of 531 (27%) Caucasians. Additionally, African American women were significantly more likely to suffer from either a breast cancer recurrence or breast cancer death (OR 1.5; 95% CI 0.70-1.41) when compared to Caucasian women. Multivariate analysis found hypertension (HR 1.22; 95% CI 0.99-1.49; p<0.05) to be statistically significant and a potential prognostic tool for disease-free survival with African American women (OR 2.96; 95% 2.25-3.90) more likely to suffer from hypertension when compared to Caucasian women. When compared to Caucasian women, Hispanics were also more likely to suffer from hypertension (OR 1.33; 95% CI 0.96-1.83). This suggests that comorbid conditions like hypertension could account for the racial disparities that exist when comparing breast cancer survival rates. Future studies should investigate this relationship further.^

Strategies for obesity prevention in child care settings: A literature review

Background. Children in the age group of 2-5 years spend substantial amount of time during the day in some kind of childcare setting. These settings are an excellent environmental infrastructure to enhance their nutrition and physical activity behavior and to promote healthy eating and physical activity habits. Due to the steep rise in overweight and obesity among children in the past three decades, it becomes essential to intervene early. There exists a need for literature on a comprehensive and sustainable approach to obesity prevention for younger children in these settings. ^ Methods. Systematic literature search was undertaken using databases like Medline Ovid, Pubmed, Medline Ebsco, and Cochrane Library. Articles published in English as well as English language abstracts of foreign articles were included. The inclusion criteria were as follows: (1) Studies conducted in any part of the world exploring relevant themes and a child care or preschool setting would be included. (2) The interventions promoted physical activity, nutrition/healthy eating/improved diet, reduced television viewing, reduced BMI, changed knowledge and behavior of children and or staff or affected policy/standards/regulations. (3) The population was children in the age group of at least 2 years to 5 years. (4) Articles published in English and English language abstracts for foreign articles would be included. ^ Results. 16 articles were included in the review that consisted of primary interventions in the form of randomized control trials or pre-post interventions were conducted in a preschool or child care or day care setting only. The outcomes pertaining to healthy weight in children were increased vegetable intake, reduced BMI and increased knowledge among others. ^ Conclusion. There is a dearth of data on strong intervention trials in the child care setting. Preschool research studies in the young children that have been conducted are not strong enough. There is a need for more randomized control trials and a well planned evaluation in the preschool age children. There is a need to develop outcome measures that can accurately assess the changes in diet and physical activity in this age group. Child care nutrition and physical activity standards need to be made stringent. ^

Workers and respirators: What factors influence medical clearance? Experience in the petrochemical industry 2004--2008

This retrospective cohort study analyzed data from more than 2200 OSHA-mandated respirator medical evaluations performed between 2004 and 2008, with information initially obtained using an online questionnaire, to determine what factors influence medical clearance and the ability to safely wear respiratory protection in a large petrochemical company.^ The employees were mostly white males with a high school education, ranging in age from 25 to 60 years of age, who had been employed with the company an average of eight years. Their work was typically performed outdoors in a rural or offshore setting. Respirators were typically required for emergency response – escape or rescue only – and/or limited to less than four hours per month.^ Approximately 90% of the population achieved medical clearance by utilizing the online questionnaire. Of the remaining 10%, 66% were cleared after additional "hands-on" medical examination exam; 28% of the individuals' jobs were modified by their supervisor in order to not use a respirator, and 6% of the individuals (n=13) were excluded from wearing a respirator on the basis of the medical examination. The primary causes for exclusion from respirator use were cardiovascular (37.5%) and respiratory (31.3%) issues, followed by psychological (18.8%) and musculoskeletal (12.5%) concerns. Ultimately, over 99% of workers evaluated under this system were found capable of using respiratory protection safely. This questionnaire has proven to be an excellent health screening tool capable of initiating early detection and further investigation of potentially serious medical conditions within a large and diverse population in multiple locations. ^

An intervention mapping approach: Identification of human trafficking victims by health professionals

Background. Today modern day slavery is known as human trafficking and is a growing pandemic that is a grave human rights violation. Estimates suggest that 12.3 million people are working under conditions of force, fraud or coercion. Working toward eradication is a worthy effort; it would free millions of humans from slavery, mostly women and children, as well as uphold basic human rights. One tactic to eradicating human trafficking is to increase identification of victims among those likely to encounter victims of human trafficking.^ Purpose. This study aims to develop an intervention that improves certain stakeholders' ability, in the health clinic setting, to appropriately identify and report victims of human trafficking to the National Human Trafficking Resource Center.^ Methods. The Intervention Mapping (IM) process was used by program planners to develop an intervention for health professionals. This methodology is a six step process that guides program planners to develop an intervention. Each step builds on the others through the execution of a needs assessment, and the development of matrices based on performance objectives and determinants of the targeted health behavior. The end product results in an ecological, theoretical, and evidence based intervention.^ Discussion. The IM process served as a useful protocol for program planners to take an ecological approach as well as incorporate theory and evidence into the intervention. Consultation with key informants, the planning group, adopters, implementers, and individuals responsible for institutionalization also contributed to the practicality and feasibility of the intervention. Program planners believe that this intervention fully meets recommendations set forth in the literature.^ Conclusions. The intervention mapping methodology enabled program planners to develop an intervention that is appropriate and acceptable to the implementer and the recipients.^

Doctor-patient communication in the medical interaction: Context, implications, and practice

Effective communication; whether from an interpersonal, mass media, or global perspective, is a critical component in public health. It is an essential conduit in increasing public awareness of available health resources, potential health hazards and related disease prevention strategies, and in delivering better health care. Within this context, available literature asserts doctor-patient communication as central to healthcare delivery. It has been shown to affect patient health outcomes, satisfaction with care, adherence to treatment recommendations, and even understanding of medical information. While research supports the essential imperative of interventions aimed at teaching doctors and patients the communication skills necessary for a successful and meaningful medical interaction, most interventions to date, focus on teaching these communication skills to doctors and seem to rely, largely, on mass media for providing patients with the information needed to increase communication efficacy. This study sought to fill a significant gap in the doctor-patient communication literature by reviewing the context of the doctor-patient exchange in the medical interaction, the implications of this exchange in resulting care of the patient, and the potential improvements to practice through interventions aimed at improving the communication exchange. Closing with an evaluation of a patient-centered communication intervention, the “How to Talk to Your Doctor” (HTTTYD) program that combines previously identified optimal strategies for improving communication between doctors and patients, this study examined the patients’ perspective of their potential as better communicators in the medical interaction. ^ Specific Aims, Hypotheses or Questions (Aim I) To examine the context of health communication within a public health framework and its relation to health care delivery. (Aim II) To review doctor-patient communication as a central focus within health care delivery and the resulting implications to patient care. (Aim III) To assess the utility of interventions to improve doctor-patient communication. Specifically, to evaluate the effectiveness of a patient-centered community education intervention, the “How to Talk to Your Doctor” (HTTTYD) program, aimed at improving patient communication efficacy.^

Early life risk factors and puberty implications for cancer prevention

Earlier age at puberty is a known risk factor for breast cancer and suspected to influence prostate cancer; yet few studies have assessed early life risk factors for puberty. The overall objectives was to determine the relationship between birth-weight-for-gestational-age (BWGA), weight gain in infancy and pubertal status in girls and boys at 10.8 and 11.8 years and who were born of preeclamptic (PE) and normotensive (NT) mothers. Data for this study were collected from hospital and public health medical records and at a follow-up visit at 10.8 and 11.8 years for girls and boys, respectively. We used stratified analysis and multivariable logistic regression modeling to assess effect measure modifier and to determine the relationship between BWGA, weight gain in infancy and childhood and pubertal status, respectively. ^ There was no difference in the relationship between BWGA and pubertal status by maternal PE status for girls and boys; however, there was a non-significant increase in the odds of having been born small-for-gestational-age (SGA) in girls who were pubertal for breast or pubic hair Tanner stage 2+ compared to those who B1 or PH1. In contrast, boys who were pubertal for genital and pubic hair Tanner stage 2+ had lower odds of having been born SGA than those who were prepubertal for G1 or PH1. ^ In girls who were pubertal for breast development, the odds of having gained one additional unit SD for weight was highest between 3 to 6 months and 6-12 months for those who were B2+ vs. B1. For pubic hair development, weight gain between 6-12 months had the greatest effect for girls of PE mothers only. In boys, there were no statistically significant associations between weight gain and genital Tanner stage at any of the intervals; however, weight gain between 3-6 months did affect pubic hair tanner stage in boys of NT mothers. This study provide important evidence regarding the role of SGA and weight gain at specific age intervals on puberty; however, larger studies need to shed light on modifiable exposures for behavioral interventions in pregnancy, postpartum and in childhood.^

Factors governing late-recurrence of disease in a cohort of early-stage breast cancer survivors

Purpose. To determine the risk of late breast cancer recurrence (5 years after treatment) in a population of women diagnosed with early-stage breast cancer at The University of Texas M.D. Anderson Cancer Center (MDACC) between 1985-2000 and to examine the effect of this population’s BMI, smoking history, reproductive history, hormone use, and alcohol intake at the time of diagnosis on risk of late recurrence.^ Methods. Patients included 1,913 members of the Early Stage Breast Cancer Repository recruited at MDACC who had survived without a recurrence for at least five years after their initial diagnosis of early stage breast cancer. Clinical and epidemiological information was ascertained twice on participants during the study—first by medical record abstraction then by patient interview at least five years after receipt of adjuvant treatment. A total of 223 late breast cancer recurrences were captured, with an average follow-up of 10.6 years. Cox proportional hazards models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI). ^

A promotora de salud CVD intervention: Participant responses after Su Corazon, Su Vida education

In this study we sought to identify and understand feelings, benefits and barriers to making heart healthy behavioral changes by reviewing and analyzing participant responses to a follow-up telephone survey conducted as part of the HEART project (Health Education Awareness Research Team). Individuals who participated in HEART attended classes and received “Su Corazon, Su Vida” education. The HEART follow-up telephone survey was conducted only on those participants who were part of the experimental group. A total of 93 individuals from this group were successfully contacted for participation in the telephone survey after the classes ended. Quantitative data regarding ‘feelings’ and ‘difficulty making heart healthy behavioral changes’ were analyzed by calculating frequencies of each category of response for post-intervention weeks 9, 13, and 15. In addition, Wilcoxon rank-sum tests were conducted for post-intervention at weeks 9, 13, and 15 to measure associations between feelings and difficulties making heart healthy behavioral changes. Changes in responses over time for feelings and difficulties making heart healthy behavioral changes were looked at by counting differences in responses between pairs of follow up weeks. Qualitative responses to the survey were analyzed by categorizing content of responses under themes in order to identify factors related to feelings and difficulties making heart healthy behavioral changes. Telephone survey participants showed positive attitudes towards making nutritional and physical activity changes. Out of the 93 telephone survey respondents, 53 (57%) reported some type of physical activity change during the follow-up period while 46 (49%) reported specific changes in nutrition. Data from the “difficulty to making changes” responses were categorized under constructs from the Health Belief Model, perceived benefits and barriers. Overall, the barriers for physical activity were health issues, individual habits and time. Barriers to eating healthy were family support, individual habits, and knowledge. This study suggests that with respect to nutritional knowledge barriers, educational programs should explore other ways of teaching and familiarizing individuals with information sources that may be more appropriate for those populations not accustomed to them. For example, nutrition labels, portions, recipes, and use of photonovelas. Our findings of the barriers to changes in food preparation due to lack of family support may also suggest the need for the development of programs where influential partners or relatives are involved in order to create a more supportive environment which may provide more opportunity for change toward healthier lifestyle behaviors. Finally, the physical activity barriers found suggest that it may be beneficial to recommend appropriate exercises for those with specific health problems or those with time restrictions due to work or travel so that physical activity is not completely avoided.^

An interactive intervention to impact adherence to antiretroviral treatment among treatment-naive HIV-infected adults in Thailand: A pilot randomized controlled study

Background. Consistent adherence to antiretroviral treatment is necessary for a treatment success. Improving and maintaining adherence rate >95% are challenging for health care professionals. This pilot randomized controlled study aimed to evaluate the impact of the interactive intervention on adherence to GPO-VIR, to describe the feasibility of the interactive intervention in Thailand, and to illustrate the adherence self-efficacy concept among HIV treatment-naïve patients in Thailand who were starting antiretroviral treatment. ^ Methods. The study took place at three HIV clinics located in Phayao, Thailand. Twenty-three patients were randomly assigned into the experimental (n=11) and the control groups (n=12). Each participant in the experimental group and a significant person to the patient received 5 educational sessions with a nurse at the clinics and at their homes. They also received 3 follow-up evaluations during the 6-month period of the study. The participants in the control group received the standard of care provided by HIV clinical personnel plus three follow-up evaluations at the clinic. ^ Results. Seventeen patients (7 in the experimental and 10 in the control group) completed the study. The 4-day recall on the Thai ACTG Adherence Scale demonstrated adherence rate >95% for most participants from both groups. After the first measurement, no experimental group patients reporting missing ART, while one control group participant continuously skipped ART. Participants from both groups had significantly increased CD4 cell counts after the study (F(1, 15) = 29.30, p = .000), but no differences were found between two groups (F(1, 15) = .001, p = .98). Examination of the intervention showed limitations and possibilities to implement it in Thailand. Qualitative data demonstrated self-efficacy expectations, resignation and acceptance as related concepts to improve adherence outcomes. ^ Conclusions. This interactive intervention, after appropriate modifications, is feasible to apply for Thai HIV-treatment naïve patients. Because of limitations the study could not demonstrate whether the interactive intervention improved adherence to ART among HIV-treatment naïve in Thailand. A longitudinal study in a larger sample would be required to test the impact of the intervention. ^ Keyword: antiretroviral treatment, adherence, treatment-naïve, Thailand, randomized controlled study ^

Community diagnosis: A working tool for developing culturally appropriate diarrhea intervention programs

Most studies related to diarrhea have been focused narrowly on the etiological and pathophysiological factors involved in inducing the disease. Such studies have often failed to consider other facets contributing to and possibly prolonging the problem, namely: socio-economic conditions, educational opportunities and attainments, cultural characteristics and beliefs, and the political administration and its commitment towards fulfilling its moral and ethical obligations in responding to and fostering human development.^ This study utilized the diagnostic approach of the PRECEDE model. The acronym stands for the predisposing reinforcing, and enabling constructs in educational diagnosis and evaluation. The constituents of this model were identified by utilizing participant observation field methods, traditionally applied by ethnographers to collect data describing the multiple facets of a culture, and linguistic anthropology used to capture and define characteristic semantics and viewpoints. The household study sample was randomly selected from a defined list of households known to have at least one child less than five years of age. An open-ended questionnaire format was used to interview the 115 mothers in the selected households sample.^ Kalama, the study community, is characteristically an agricultural village, situated in the Governorate of Kaliobia and located approximately 25 Km (about 15.5 miles) from the capital, Cairo, Egypt. The 1986 census indicates a population size of 13,328 people in 4,818 households. There were 65 deaths occurring among children less than five years in 1986. The causes of death were primarily related to diarrhea, followed by upper respiratory infections, congenital anomalies and birth injuries.^ This study outlines (a) practices related to the management of diarrhea, including the administration of foods and drinks during such episodes; (b) influences of governmental policies; and (c) recommended strategies for overcoming barriers and promoting effective diarrhea intervention programs. ^

A descriptive study of the sociodemographic, health and developmental factors associated with slow learning in children from upper to middle social class families in Texas

"Slow Learners" is a term used to describe children with an IQ range of 70-89 on a standardized individual intelligence test (i.e. with a standard deviation of either 15 or 16). They have above retarded, but below average intelligence and potential to learn. If the factors associated with the etiology of slow learning in children can be identified, it may be possible to hypothesize causal relationships which can be tested by intervention studies specifically designed to prevent slow learning. If effective, these may ultimately reduce the incidence of school dropouts and their cost to society. To date, there is little information about variables which may be etiologically significant. In an attempt to identify such etiologic factors this study examines the sociodemographic characteristics, prenatal history (hypertension, smoking, infections, medication, vaginal bleeding, etc.), natal history (length of delivery, Apgar score, birth trauma, resuscitation, etc.), neonatal history (infections, seizures, head trauma, etc.), developmental history (health problems, developmental milestones and growth during infancy and early childhood), and family history (educational level of the parents, occupation, history of similar condition in the family, etc.) of a series of children defined as slow learners. The study is limited to children from middle to high socioeconomic families in order to exclude the possible confounding variable of low socioeconomic status, and because a descriptive study of this group has not been previously reported. ^

Procedure for the identification of population characteristics for targeting intervention services on the basis of outcome-goal priorities: Case management services for the chronic mentally ill

Although the processes involved in rational patient targeting may be obvious for certain services, for others, both the appropriate sub-populations to receive services and the procedures to be used for their identification may be unclear. This project was designed to address several research questions which arise in the attempt to deliver appropriate services to specific populations. The related difficulties are particularly evident for those interventions about which findings regarding effectiveness are conflicting. When an intervention clearly is not beneficial (or is dangerous) to a large, diverse population, consensus regarding withholding the intervention from dissemination can easily be reached. When findings are ambiguous, however, conclusions may be impossible.^ When characteristics of patients likely to benefit from an intervention are not obvious, and when the intervention is not significantly invasive or dangerous, the strategy proposed herein may be used to identify specific characteristics of sub-populations which may benefit from the intervention. The identification of these populations may be used both in further informing decisions regarding distribution of the intervention and for purposes of planning implementation of the intervention by identifying specific target populations for service delivery.^ This project explores a method for identifying such sub-populations through the use of related datasets generated from clinical trials conducted to test the effectiveness of an intervention. The method is specified in detail and tested using the example intervention of case management for outpatient treatment of populations with chronic mental illness. These analyses were applied in order to identify any characteristics which distinguish specific sub-populations who are more likely to benefit from case management service, despite conflicting findings regarding its effectiveness for the aggregate population, as reported in the body of related research. However, in addition to a limited set of characteristics associated with benefit, the findings generated, a larger set of characteristics of patients likely to experience greater improvement without intervention. ^