The uses of the outline for cultural formulation of the DSM-IV : from case conceptualization to treatment plan

ARTICLE 1 : RÉSUMÉ Amputation traumatique: Une étude de cas laotien sur l’indignation et l’injustice. La culture est un contexte essentiel à considérer pour produire un diagnostic et un plan d’intervention psychiatrique. Une perspective culturelle met en relief le contexte social dans lequel les symptômes émergent, et comment ils sont interprétés et gérés par la personne atteinte. Des études ethnoculturelles sur les maladies nous suggèrent que la plupart des gens nous donnent des explications pour leurs symptômes qui ont un fondement culturel. Bien que ces explications contredisent la théorie biomédicale, elles soulagent la souffrance des patients et leur permettent de donner une signification à cette dernière. L’exploration des caractéristiques, contextes et antécédents des symptômes permet au patient de les communiquer au clinicien qui pourrait avoir une explication différente de sa maladie. Cette étude de cas permet de montrer comment le Guide pour Formulation Culturelle du DSM-IV (The DSM-IV Outline for Cultural Formulation) permet aux cliniciens de solliciter un récit du patient en lien avec son expérience de la maladie. Notre étude examine l’utilisation par un patient laotien de « l’indignation sociale » (« Khuâm khum khang ») comme le modèle explicatif culturel de son problème malgré le diagnostic de trouble de stress post-traumatique qui lui fut attribué après une amputation traumatique. L’explication culturelle de son problème a permis au patient d’exprimer la signification personnelle et collective à sa colère et sa frustration, émotions qu’il avait réprimées. Cet idiome culturel lui a permis d’exprimer sa détresse et de réfléchir sur le système de soins de santé et, plus précisément, le contexte dans lequel les symptômes et leurs origines sont racontés et évalués. Cette représentation laotienne a aussi permis aux cliniciens de comprendre des expériences et les explications du client, autrement difficiles à situer dans un contexte biomédical et psychiatrique Euro-américain. Cette étude démontre comment il est possible d’améliorer les interactions entre cliniciens et patients et dès lors la qualité des soins par la compréhension de la perspective du patient et l’utilisation d’une approche culturelle. Mots clés: Culture, signification, idiome culturel, modèle explicatif, Guide pour Formulation culturelle du DSM-IV, indignation sociale, interaction entre patient et intervenant. ARTICLE 2 : RÉSUMÉ Impact de l’utilisation du Guide pour la formulation culturelle du DSM-IV sur la dynamique de conférences multidisciplinaires en santé mentale. La croissance du pluralisme culturel en Amérique du nord a obligé la communauté oeuvrant en santé mentale d’adopter une sensibilité culturelle accrue dans l’exercice de leur métier. Les professionnels en santé mentale doivent prendre conscience du contexte historique et social non seulement de leur clientèle mais également de leur propre profession. Les renseignements exigés pour les soins professionnels proviennent d’ évaluations cliniques. Il faut examiner ces informations dans un cadre culturellement sensible pour pouvoir formuler une évaluation des cas qui permet aux cliniciens de poser un diagnostic juste et précis, et ce, à travers les frontières culturelles du patient aussi bien que celles du professionnel en santé mentale. Cette situation a suscité le développement du Guide pour la formulation culturelle dans la 4ième édition du Manuel diagnostique et statistique des troubles mentaux américain (Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV) de l’Association psychiatrique américaine. Ce guide est un outil pour aider les cliniciens à obtenir des informations de nature culturelle auprès du client et de sa famille afin de guider la production des soins en santé mentale. L’étude vise l’analyse conversationnelle de la conférence multidisciplinaire comme contexte d’utilisation du Guide pour la formulation culturelle qui sert de cadre dans lequel les pratiques discursives des professionnels de la santé mentale évoluent. Utilisant la perspective théorique de l’interactionnisme symbolique, l’étude examine comment les diverses disciplines de la santé mentale interprètent et conceptualisent les éléments culturels et les implications de ce cadre pour la collaboration interdisciplinaire dans l’évaluation, l’élaboration de plans de traitement et des soins. Mots clé: Guide pour Formulation culturelle – Santé mentale – Psychiatrie transculturelle – Analyse conversationnelle – Interactionnisme symbolique

Mental health treatment seeking by military members with posttraumatic stress disorder : findings on rates, characteristics, and predictors from a nationally representative Canadian military sample

Objective: The goal of this study was to identify rates, characteristies, and predictors of mental health treatment seeking by military members with posttraumatic stress disorder (PTSD). Method: Our sample was drawn from the 2002 Canadian Community Health Survey-Canadian Forces Supplement (CCHS-CF) dataset. The CCHS-CF is the first epidemiologic survey of PTSD and other mental health conditions in the Canadian military and includes 8441 nationally representative Canadian Forces (CF) members. Of those, 549 who met the criteria for lifetime PTSD were included in our analyses. To identify treatment rates and characteristics, we examined frequency of treatment contact by professional and facility type. To identify predictors of treatment seeking, we conducted a binary logistic regression with lifetime treatment seeking as the outcome variable. Results: About two-thirds of those with PTSD consulted with a professional regarding mental health problems. The most frequently consulted professionals, during both the last year and lifetime, included social workers and counsellors, medical doctors and general practitioners, and psychiatrists. Consultations during the last year most often took place in a CF facility. Treatment seeking was predicted by cumulative lifetime trauma exposure, index traumatic event type, PTSD symptom interference, and comorbid major depressive disorder. Those with comorbid depression were 3.75 times more likely to have sought treatment than those without. Conclusions: Although a significant portion of military members with PTSD sought mental health treatment, 1 in 3 never did. Trauma-related and illness and (or) need factors predicted treatment seeking. Of all the predictors of treatment seeking, comorbid depression most increased the likelihood of seeking treatment.

Ecology And Seasonal Variation Of Microalgal Community In An Oil Refinery Effluent Holding Pond: Monitoring And Assessment

The microalgal community as primary producers has to play a significant role in the biotic and abitoic interactions of any aquatic ecosystem. Whenever a community is exposed to a pollutant, responses can occur because individuals acclimate to pollutant caused changes and selection can occur favouring resistant genotypes within a population and selection among species can result in changes in community structure. The microalgal community of industrial effluent treatment systems are continuously exposed to pollutants and there is little data available on the structure and seasonal variation of microalgal community of industrial effluent holding ponds, especially of a complex effluent like that of refinery. The aim of the present study was to investigate the annual variation in the ecology, biomass, productivity and community structure of the algal community of a refinery effluent holding pond. The results of the study showed the pond to be a eutrophic system with a resistant microalgal community with distinct seasonal variation in species composition

Effects of grassland conversion and tillage intensities on soil microbial biomass, residues and community structure

Agricultural intensification has a strong impact on level of soil organic matter (SOM), microbial biomass stocks and microbial community structure in agro-ecosystems. The size of the microbial necromass C pool could be about 40 times that of the living microbial biomass C pool in soils. Due to the specificity, amino sugar analysis gives more important information on the relative contribution of fungal and bacterial residues to C sequestration potential of soils. Meanwhile, the relationship between microbial biomass and microbial necromass in soil and its ecological significance on SOM are not fully understood and likely to be very complex in grassland soils. This thesis focuses on the effects of tillage, grassland conversion intensities and fertilisation on microbial biomass, residues and community structure. The combined analyses of microbial biomass and residue formation of both fungi and bacteria provided a unique opportunity to study the effect of tillage, grassland conversion and fertilisation on soil microbial dynamics. In top soil at 0-30 cm layer, a reduction in tillage intensity by the GRT and NT treatments increased the accumulation of saprotrophic fungi in comparison with the MBT treatment. In contrast, the GRT and NT treatments promoted AMF at the expense of saprotrophic fungi in the bottom soil layer at 30-40 cm depth. The negative relationship between the ergosterol to microbial biomass C ratio and the fungal C to bacterial C ratio points to the importance of the relationship between saprotrophic fungi and biotrophic AMF for tillage-induced changes in microbial turnover of SOC. One-season cultivation of winter wheat with two tillage events led to a significant loss in SOC and microbial biomass C stocks at 0-40 cm depth in comparison with the permanent grassland, even 5 years after the tillage event. However, the tillage induced loss in microbial biomass C was roughly 40% less in the long-term than in the short-term of the current experiment, indicating a recovery process during grassland restoration. In general, mould board tillage and grassland conversion to maize monoculture promoted saprotrophic fungi at the expense of biotrophic AMF and bacteria compared to undisturbed grassland soils. Slurry application promoted bacterial residues as indicated by the decreases in both, the ergosterol to microbial biomass C ratio and the fungal C to bacterial C ratio. In addition, the lost microbial functional diversity due to tillage and maize monoculture was restored by slurry application both in arable and grassland soils. I conclude that the microbial biomass C/S ratio can be used as an additional indicator for a shift in microbial community. The strong relationships between microbial biomass and necromass indices points to the importance of saprotrophic fungi and biotrophic AMF for agricultural management induced effects on microbial turnover and ecosystem C storage. Quantitative information on exact biomass estimates of these two important fungal groups in soil is inevitably necessary to understand their different roles in SOM dynamics.

Wastewater Treatment Project for Palma Soriano, Cuba: Assessment of Cultural and Ecological Conditions

The Palma Project is an experiment in the use of cultural identity as a social trigger to address ecological degradation. The research methodology draws from environmental, social and urban analyses to unveil the best strategy to address the ecological, river restoration and water treatment challenges in Berkeley, California’s “Sister City” in southeast Cuba, Palma Soriano. The objective is to provide a better quality of life and to create new opportunities for the local community to reconnect with natural cycles of water and the cultivation of their own land. The project aim is to promote the strength and capacity of local communities to protect their own environment based upon a master plan, which includes natural wastewater treatment, reforestation, urban agriculture and the facilitation and utilization of a public space bordering the major river which flows by Palma Soriano, the Cauto. This project will contribute and produce healthy water recycling for Palma, provide a potable water source for the city, encourage ecological restoration of the riparian zone of the Cauto, and provide new opportunities for food production. It is designed to preserve the cultural identity of the local community, and to restore the essential balance between the community’s need to sustain both itself and the natural environment.

A psychological treatment programme for traumatised exmilitary personnel in the UK

A large proportion of homeless people in the UK are former members of the armed services and suffer from a mental illness. In fact, homelessness itself can be considered a symptom or manifestation of other underlying psychological difficulties. For these reasons Community Housing and Therapy (CHT) considers that providing psychological therapies to treat the homeless population is a more effective way of tackling the problem of homelessness, as it addresses the roots of the problem. This approach is one which is beginning to be recognized by leading agencies in the field. At the same time, the provision of psychological therapies for symptoms such as depression and anxiety has become accepted through the Department of Health’s (DoH) Increased Access to Psychological Therapies ( IAPT) initiative. Depression is the most common psychiatric disorder that homeless people suffer and it is well documented that psychological treatments for depression can be extremely effective. As well as approaching homelessness from the angle of psychological therapies, CHT in its work with the ex-service community has become increasingly aware that there are a large number of non statutory homeless that do not get the same attention as rough sleepers.

Conceptual design of wastewater treatment plants using multiple objectives

La implementació de la Directiva Europea 91/271/CEE referent a tractament d'aigües residuals urbanes va promoure la construcció de noves instal·lacions al mateix temps que la introducció de noves tecnologies per tractar nutrients en àrees designades com a sensibles. Tant el disseny d'aquestes noves infraestructures com el redisseny de les ja existents es va portar a terme a partir d'aproximacions basades fonamentalment en objectius econòmics degut a la necessitat d'acabar les obres en un període de temps relativament curt. Aquests estudis estaven basats en coneixement heurístic o correlacions numèriques provinents de models determinístics simplificats. Així doncs, moltes de les estacions depuradores d'aigües residuals (EDARs) resultants van estar caracteritzades per una manca de robustesa i flexibilitat, poca controlabilitat, amb freqüents problemes microbiològics de separació de sòlids en el decantador secundari, elevats costos d'operació i eliminació parcial de nutrients allunyant-les de l'òptim de funcionament. Molts d'aquestes problemes van sorgir degut a un disseny inadequat, de manera que la comunitat científica es va adonar de la importància de les etapes inicials de disseny conceptual. Precisament per aquesta raó, els mètodes tradicionals de disseny han d'evolucionar cap a sistemes d'avaluació mes complexos, que tinguin en compte múltiples objectius, assegurant així un millor funcionament de la planta. Tot i la importància del disseny conceptual tenint en compte múltiples objectius, encara hi ha un buit important en la literatura científica tractant aquest camp d'investigació. L'objectiu que persegueix aquesta tesi és el de desenvolupar un mètode de disseny conceptual d'EDARs considerant múltiples objectius, de manera que serveixi d'eina de suport a la presa de decisions al seleccionar la millor alternativa entre diferents opcions de disseny. Aquest treball de recerca contribueix amb un mètode de disseny modular i evolutiu que combina diferent tècniques com: el procés de decisió jeràrquic, anàlisi multicriteri, optimació preliminar multiobjectiu basada en anàlisi de sensibilitat, tècniques d'extracció de coneixement i mineria de dades, anàlisi multivariant i anàlisi d'incertesa a partir de simulacions de Monte Carlo. Això s'ha aconseguit subdividint el mètode de disseny desenvolupat en aquesta tesis en quatre blocs principals: (1) generació jeràrquica i anàlisi multicriteri d'alternatives, (2) anàlisi de decisions crítiques, (3) anàlisi multivariant i (4) anàlisi d'incertesa. El primer dels blocs combina un procés de decisió jeràrquic amb anàlisi multicriteri. El procés de decisió jeràrquic subdivideix el disseny conceptual en una sèrie de qüestions mes fàcilment analitzables i avaluables mentre que l'anàlisi multicriteri permet la consideració de diferent objectius al mateix temps. D'aquesta manera es redueix el nombre d'alternatives a avaluar i fa que el futur disseny i operació de la planta estigui influenciat per aspectes ambientals, econòmics, tècnics i legals. Finalment aquest bloc inclou una anàlisi de sensibilitat dels pesos que proporciona informació de com varien les diferents alternatives al mateix temps que canvia la importància relativa del objectius de disseny. El segon bloc engloba tècniques d'anàlisi de sensibilitat, optimització preliminar multiobjectiu i extracció de coneixement per donar suport al disseny conceptual d'EDAR, seleccionant la millor alternativa un cop s'han identificat decisions crítiques. Les decisions crítiques són aquelles en les que s'ha de seleccionar entre alternatives que compleixen de forma similar els objectius de disseny però amb diferents implicacions pel que respecte a la futura estructura i operació de la planta. Aquest tipus d'anàlisi proporciona una visió més àmplia de l'espai de disseny i permet identificar direccions desitjables (o indesitjables) cap on el procés de disseny pot derivar. El tercer bloc de la tesi proporciona l'anàlisi multivariant de les matrius multicriteri obtingudes durant l'avaluació de les alternatives de disseny. Específicament, les tècniques utilitzades en aquest treball de recerca engloben: 1) anàlisi de conglomerats, 2) anàlisi de components principals/anàlisi factorial i 3) anàlisi discriminant. Com a resultat és possible un millor accés a les dades per realitzar la selecció de les alternatives, proporcionant més informació per a una avaluació mes efectiva, i finalment incrementant el coneixement del procés d'avaluació de les alternatives de disseny generades. En el quart i últim bloc desenvolupat en aquesta tesi, les diferents alternatives de disseny són avaluades amb incertesa. L'objectiu d'aquest bloc és el d'estudiar el canvi en la presa de decisions quan una alternativa és avaluada incloent o no incertesa en els paràmetres dels models que descriuen el seu comportament. La incertesa en el paràmetres del model s'introdueix a partir de funcions de probabilitat. Desprès es porten a terme simulacions Monte Carlo, on d'aquestes distribucions se n'extrauen números aleatoris que es subsisteixen pels paràmetres del model i permeten estudiar com la incertesa es propaga a través del model. Així és possible analitzar la variació en l'acompliment global dels objectius de disseny per a cada una de les alternatives, quines són les contribucions en aquesta variació que hi tenen els aspectes ambientals, legals, econòmics i tècnics, i finalment el canvi en la selecció d'alternatives quan hi ha una variació de la importància relativa dels objectius de disseny. En comparació amb les aproximacions tradicionals de disseny, el mètode desenvolupat en aquesta tesi adreça problemes de disseny/redisseny tenint en compte múltiples objectius i múltiples criteris. Al mateix temps, el procés de presa de decisions mostra de forma objectiva, transparent i sistemàtica el perquè una alternativa és seleccionada en front de les altres, proporcionant l'opció que més bé acompleix els objectius marcats, mostrant els punts forts i febles, les principals correlacions entre objectius i alternatives, i finalment tenint en compte la possible incertesa inherent en els paràmetres del model que es fan servir durant les anàlisis. Les possibilitats del mètode desenvolupat es demostren en aquesta tesi a partir de diferents casos d'estudi: selecció del tipus d'eliminació biològica de nitrogen (cas d'estudi # 1), optimització d'una estratègia de control (cas d'estudi # 2), redisseny d'una planta per aconseguir eliminació simultània de carboni, nitrogen i fòsfor (cas d'estudi # 3) i finalment anàlisi d'estratègies control a nivell de planta (casos d'estudi # 4 i # 5).

Changing precipitation patterns alter plant community dynamics and succession in an ex-arable grassland

1. Changes in the frequency of extreme events, such as droughts, may be one of the most significant impacts of climate change for ecosystems. Models predict more frequent summer droughts in much of England: this paper investigates the impact on different types of plants in an ex-arable grassland community. 2. A long-term experiment simulated increased and decreased summer precipitation. Substantial interannual variation allowed the effects of summer drought to be tested in combination with wet and dry weather in other seasons. This is important, as climate models predict increased winter precipitation. 3. Total cover abundance in early summer increased with increasing water supply in the previous summer; there was no effect of winter precipitation. Productivity is therefore likely to decrease with more frequent summer droughts, with no mitigating effect of wetter winters. 4. The percentage cover of perennial grasses declined during a natural drought in 1995-97; this was exacerbated by the experimental drought treatment and reduced by supplemented rainfall. Simultaneously, short-lived ruderal species increased; this was greatest in drought treatments and least with supplemented rainfall. 4. These trends were subsequently reversed during several years of unusually wet weather, with perennial grasses increasing and short-lived forbs decreasing. This occurred even in experimentally droughted plots, and we propose that it resulted from rapid coverage of gaps during wet autumns and winters. 6. Deep-rooted species generally proved to be more drought resistant, but there were exceptions. 7. We conclude that increased frequency of summer droughts could have serious implications for the establishment and successional development of ex-arable grasslands. Increased winter precipitation would moderate the impact on species composition, but not on productivity.

A follow-up study of characteristics of young people that dropout and continue psychotherapy: service implications for a clinic in the community

Background: The paper reports the findings from a follow-up study of the factors that contribute to whether young people dropout or continue once-weekly psychotherapy at a voluntary sector psychotherapy service for young people aged 12 to 21 years. Method: The study uses data from an ongoing audit of the psychotherapy service that started in 1993; 882 young people were included in the study. Premature termination of treatment was defined as dropping out before the 21st session. Continuation in treatment was defined as remaining in therapy after 20 sessions. Measures and areas of interest used in the study include diagnostic measures, the Youth Self Report Form and Young Adult Self Report Form, demographic characteristics and treatment related information. Results: Young people who continued in treatment were more likely to be older, have anxieties about sexual and relationship issues and have higher scores on self-reported anxiety-depression. Young people who dropped out of treatment were more likely to be younger, have higher self-reported delinquency scores, have a diagnosis of hyperactivity-conduct disorder and be homeless. Conclusions: The study of treatment termination has demonstrated the value of service audit and has led to a significant change in clinical practice.

Nanoscale zerovalent iron alters soil bacterial community structure and inhibits chloroaromatic biodegradation potential in Aroclor 1242-contaminated soil

Nanoscale zerovalent iron (nZVI) has potential for the remediation of organochlorine-contaminated environments. Environmental safety concerns associated with in situ deployment of nZVI include potential negative impacts on indigenous microbes whose biodegradative functions could contribute to contaminant remediation. With respect to a two-step polychlorinated biphenyl remediation scenario comprising nZVI dechlorination followed by aerobic biodegradation, we examined the effect of polyacrylic acid (PAA)-coated nZVI (mean diameter = 12.5 nm) applied at 10 g nZVI kg−1 to Aroclor-1242 contaminated and uncontaminated soil over 28 days. nZVI had a limited effect on Aroclor congener profiles, but, either directly or indirectly via changes to soil physico-chemical conditions (pH, Eh), nZVI addition caused perturbation to soil bacterial community composition, and reduced the activity of chloroaromatic mineralizing microorganisms. We conclude that nZVI addition has the potential to inhibit microbial functions that could be important for PCB remediation strategies combining nZVI treatment and biodegradation.

Children and adolescents referred for treatment of anxiety disorders: differences in clinical characteristics

Background: Reports of the clinical characteristics of children and adolescents with anxiety disorders are typically based on community populations or from clinical samples with exclusion criterion applied. Little is known about the clinical characteristics of children and adolescents routinely referred for treatment for anxiety disorders. Furthermore, children and adolescents are typically treated as one homogeneous group although they may differ in ways that are clinically meaningful. Methods: A consecutive series of children (n = 100, aged 6-12 years) and adolescents (n = 100, aged 13-18 years), referred to a routine clinical service, were assessed for anxiety and comorbid disorders, school refusal and parental symptoms of psychopathology. Results: Children were significantly more likely to be diagnosed with separation anxiety disorder than adolescents. Adolescents with a primary anxiety disorder had significantly higher self and clinician rated anxiety symptoms and had more frequent primary diagnoses of social anxiety disorder, diagnoses and symptoms of mood disorders, and irregular school attendance. Limitations: Childhood and adolescence were considered categorically as distinct, developmental periods; in reality changes would be unlikely to occur in such a discrete manner. Conclusions: The finding that children and adolescents with anxiety disorders have distinct clinical characteristics has clear implications for treatment. Simply adapting treatments designed for children to make the materials more ‘adolescent-friendly’ is unlikely to sufficiently meet the needs of adolescents.

Endophytic bacterial community composition in wheat (Triticum aestivum) is determined by plant tissue type, developmental stage and soil nutrient availability

Aims: To understand effects of tissue type, growth stage and soil fertilisers on bacterial endophyte communities of winter wheat (Triticum aestivum cv. Hereward). Methods: Endophytes were isolated from wheat grown under six fertiliser conditions in the long term Broadbalk Experiment at Rothamsted Research, UK. Samples were taken in May and July from root and leaf tissues. Results: Root and leaf communities differed in abundance and composition of endophytes. Endophytes were most abundant in roots and the Proteobacteria were most prevalent. In contrast, Firmicutes and Actinobacteria, the Gram positive phyla, were most prevalent in the leaves. Both fertiliser treatment and sample time influenced abundance and relative proportions of each phylum and genus in the endosphere. A higher density of endophytes was found in the Nil input treatment plants. Conclusions: Robust isolation techniques and stringent controls are critical for accurate recovery of endophytes. The plant tissue type, plant growth stage, and soil fertiliser treatment all contribute to the composition of the endophytic bacterial community in wheat. These results should help facilitate targeted development of endophytes for beneficial applications in agriculture.

Graceful remedies: understanding grace in the Catholic Church's treatment of clerical child sexual abuse

This article examines advocacy of Catholic restorative justice for clerical child sexual abuse from the standpoint of feminist criminological critiques of the use of restorative mediation in sexual offence cases. In particular, it questions the Catholic invocation of grace and forgiveness of survivors of abuse in light of critical feminist concerns about the exploitation of emotions in restorative practices, especially in regard to sexual and other gender-based offences. In the context of sexual abuse, the Catholic appeal to grace has the potential for turning into an extraordinary demand made of victims not only to rehabilitate offenders and the church in the eyes of the community, but also to work towards the spiritual absolution of the abuser. This unique feature of Catholic-oriented restorative justice raises important concerns in terms of feminist critiques of the risk of abuses of power within mediation, and is also incompatible with orthodox restorative justice theory, which, although it advocates a ‘spiritual’ response to crime, is concerned foremost with the rights, needs and experiences of victims.

Effectiveness of artemether-lumefantrine provided by community health workers in under-five children with uncomplicated malaria in rural Tanzania : an open label prospective study

Background: Home-management of malaria (HMM) strategy improves early access of anti-malarial medicines to high-risk groups in remote areas of sub-Saharan Africa. However, limited data are available on the effectiveness of using artemisinin-based combination therapy (ACT) within the HMM strategy. The aim of this study was to assess the effectiveness of artemether-lumefantrine (AL), presently the most favoured ACT in Africa, in under-five children with uncomplicated Plasmodium falciparum malaria in Tanzania, when provided by community health workers (CHWs) and administered unsupervised by parents or guardians at home. Methods: An open label, single arm prospective study was conducted in two rural villages with high malaria transmission in Kibaha District, Tanzania. Children presenting to CHWs with uncomplicated fever and a positive rapid malaria diagnostic test (RDT) were provisionally enrolled and provided AL for unsupervised treatment at home. Patients with microscopy confirmed P. falciparum parasitaemia were definitely enrolled and reviewed weekly by the CHWs during 42 days. Primary outcome measure was PCR corrected parasitological cure rate by day 42, as estimated by Kaplan-Meier survival analysis. This trial is registered with ClinicalTrials.gov, number NCT00454961. Results: A total of 244 febrile children were enrolled between March-August 2007. Two patients were lost to follow up on day 14, and one patient withdrew consent on day 21. Some 141/241 (58.5%) patients had recurrent infection during follow-up, of whom 14 had recrudescence. The PCR corrected cure rate by day 42 was 93.0% (95% CI 88.3%-95.9%). The median lumefantrine concentration was statistically significantly lower in patients with recrudescence (97 ng/mL [IQR 0-234]; n = 10) compared with reinfections (205 ng/mL [114-390]; n = 92), or no parasite reappearance (217 [121-374] ng/mL; n = 70; p <= 0.046). Conclusions: Provision of AL by CHWs for unsupervised malaria treatment at home was highly effective, which provides evidence base for scaling-up implementation of HMM with AL in Tanzania.