Beneficiaries Of Interventions Research Articles

A qualitative assessment of the impact of a community-embedded intervention on beneficiaries' attitudes and beliefs about adolescent sexual reproductive health in Ebonyi State, Southeast, Nigeria

BackgroundAdolescents and their communities in Ebonyi State, Nigeria have poor attitudes and beliefs towards adolescent sexual and reproductive health (SRH). This paper reports on the effects of a community-embedded intervention that focused on creating positive changes in the attitudes and beliefs of adolescents and community members to enhance adolescents’ access to SRH information and services. MethodsThis study adopted the Qualitative Impact Assessment approach to evaluate the changes in attitudes and beliefs about the SRH of adolescents from the perspectives of the beneficiaries of a community-embedded intervention namely, adolescents, parents, school teachers, and community leaders. The intervention was implemented in six local government areas in Ebonyi State, southeast Nigeria and the evaluation was undertaken four months after the implementation of the interventions commenced. Eighteen (18) interviews were conducted with 82 intervention beneficiaries including: (i) six in-depth interviews with school teachers; (ii) two sex-disaggregated FGDs with parents; (iii) two sex-disaggregated FGDs with community leaders; and (iv) eight sex-disaggregated FGDs with in school and out of school adolescents. A thematic analysis of data was performed with the aid of NVivo software, version 12.ResultsThe community-embedded intervention led to changes in individual attitudes and beliefs, as well as changes in community norms and values concerning adolescent SRH. Adolescents reported that following the community-embedded SRH intervention, they have become more comfortable discussing openly SRH issues with their peers, and they could more easily approach their parents and initiate SRH discussions. The parents of adolescents reported that following the intervention, they have become more willing to discuss sensitive SRH issues with adolescents, and frequently make out time to do so. It was also reported that parents no longer use euphemisms to describe sexual body parts, and community leaders now believe that it is all right to discuss SRH with adolescents. Hence, initiating or having SRH discussions with adolescents is no longer misconceived as encouraging sex, and menstruation in unmarried adolescents is no longer viewed as a sign of promiscuity. Respondents also highlighted changes in community norms of, (i) gendered parental communication of SRH matters, as both mothers and fathers have started discussing SRH issues with their adolescent boys and girls; and (ii) public shaming and discipline of pregnant teenage girls are on the decline.ConclusionThe community-based intervention had a positive impact on individual attitudes and beliefs, as well as community and societal values and norms about adolescent SRH. Interventions that take into account community norms and values regarding adolescent SRH should be prioritized to enable the achievement of the SRH-related target of SDG 3.

A Data-driven Model for Sustainable Deployment of Climate Smart Agriculture Practices Among Smallholder Farmers in Kakamega

Kenya’s agriculture is dominated by millions of smallholder farmers who produce over 75 percent of the national agricultural production. The smallholder farmers, however, are the most vulnerable to climate change because various socioeconomics, demography, and policy trends limit their capacity to adapt to change. To mitigate against the negative effects of climate change on smallholder farmers’ numerous interventions, in the form of Climate Smart Agriculture Technologies have been developed and promoted by development partners and government departments. Not all the targeted smallholder farmers, however, participate in and adopt the technologies at the ideal rates and intensity leading to their dis-adoption and abandonment. This study, therefore, sought to develop a data-driven model for the sustainable deployment and adoption of CSA practices among smallholder farmers in Kakamega County. The study employed a mixed methods research design. Through a quantitative survey of 428 smallholder Climate Smart Agriculture Technology adopters and dis-adopters, this study reviewed and investigated the major socio-economic and biophysical characteristics of the different smallholder farmer categories. Supervised Machine Learning using the Scikit-Learn library of Python Programming language to build, pilot, and review Decision Tree and Random Forest Classifier models for the sustainable deployment and adaptation of CSA practices among Kakamega County's smallholder farmers. 19 key variables were identified for developing a predictive model for CSA Technology adoption. A predictive tool was developed and piloted among 15 smallholder CSA farmers. The classifier model produced a Mean Squared Error of 0.16. The proposed model predicted smallholder farmer adoption at an accuracy of 89.53 percent and 90.0 percent with test data and pilot data, respectively. This study, therefore, proposes a new model for the optimal selection of Climate Smart Agriculture intervention beneficiaries.

Effects of the Million Hearts Model on Myocardial Infarctions, Strokes, and Medicare Spending

The Million Hearts Model paid health care organizations to assess and reduce cardiovascular disease (CVD) risk. Model effects on long-term outcomes are unknown. To estimate model effects on first-time myocardial infarctions (MIs) and strokes and Medicare spending over a period up to 5 years. This pragmatic cluster-randomized trial ran from 2017 to 2021, with organizations assigned to a model intervention group or standard care control group. Randomized organizations included 516 US-based primary care and specialty practices, health centers, and hospital-based outpatient clinics participating voluntarily. Of these organizations, 342 entered patients into the study population, which included Medicare fee-for-service beneficiaries aged 40 to 79 years with no previous MI or stroke and with high or medium CVD risk (a 10-year predicted probability of MI or stroke [ie, CVD risk score] ≥15%) in 2017-2018. Organizations agreed to perform guideline-concordant care, including routine CVD risk assessment and cardiovascular care management for high-risk patients. The Centers for Medicare & Medicaid Services paid organizations to calculate CVD risk scores for Medicare fee-for-service beneficiaries. CMS further rewarded organizations for reducing risk among high-risk beneficiaries (CVD risk score ≥30%). Outcomes included first-time CVD events (MIs, strokes, and transient ischemic attacks) identified in Medicare claims, combined first-time CVD events from claims and CVD deaths (coronary heart disease or cerebrovascular disease deaths) identified using the National Death Index, and Medicare Parts A and B spending for CVD events and overall. Outcomes were measured through 2021. High- and medium-risk model intervention beneficiaries (n = 130 578) and standard care control beneficiaries (n = 88 286) were similar in age (median age, 72-73 y), sex (58%-59% men), race (7%-8% Black), and baseline CVD risk score (median, 24%). The probability of a first-time CVD event within 5 years was 0.3 percentage points lower for intervention beneficiaries than control beneficiaries (3.3% relative effect; adjusted hazard ratio [HR], 0.97 [90% CI, 0.93-1.00]; P = .09). The 5-year probability of combined first-time CVD events and CVD deaths was 0.4 percentage points lower in the intervention group (4.2% relative effect; HR, 0.96 [90% CI, 0.93-0.99]; P = .02). Medicare spending for CVD events was similar between the groups (effect estimate, -$1.83 per beneficiary per month [90% CI, -$3.97 to -$0.30]; P = .16), as was overall Medicare spending including model payments (effect estimate, $2.11 per beneficiary per month [90% CI, -$16.66 to $20.89]; P = .85). The Million Hearts Model, which encouraged and paid for CVD risk assessment and reduction, reduced first-time MIs and strokes. Results support guidelines to use risk scores for CVD primary prevention. ClinicalTrials.gov Identifier: NCT04047147.

WHAT HAS CHANGED WITH DEVELOPMENT IN NIGERIA’S NIGER DELTA REGION? THE CHALLENGING TRAJECTORIES OF A CURRENT DAY INTERVENTIONIST INSTITUTION

The Niger Delta regional development question predates Nigeria’s political independence and the complexities that characterise it explains why the myriad of state responses to answering it has persisted. The Niger Delta Development Commission (NDDC) as one such response has over the years made attempts to provide viable and sustainable answers. However, given the current global uncertainties, the changing narratives with development in relation to how the NDDC has administered the needed socio-economic and infrastructural transformation in the region needs proper documentation. This is with the aim of underscoring current day institutional relational dynamics within the NDDC and how it affects development outcomes for people who are daily roped with multidimensional problems despite the avalanche of human and natural resources. The study employs an exploratory research design, using semi-structured Key Informant Interviews drawn from urban and rural based community leaders, women groups, youth groups, and Nongovernmental Organisations whose activities relate to development in Bayelsa, Delta and Rivers States. Other Key Informant Interviewees were two academic staff of the Department of Political Science, Ignatius Ajuru University of Education, Port Harcourt, and two staff of the NDDC. David Easton’s Systems Theory is adopted to explain the input-output nexus between beneficiaries of interventions and the NDDC and how that affects development outcomes in the region. The study reveals the current administrative imbroglio between the Ministry of Niger Delta Affairs and the NDDC as a new challenge and threat to achieving sustainable development in the region. This challenge as revealed by the study has aggravated issues of poor institutional planning, poor community interface mechanisms, poor monitoring and evaluation, and the aggressive nature of interventions. The study concludes that although these challenges do not subvert the relative transformation achieved so far by the NDDC, however, such relativity suggests that the desired change in development is not substantial enough to alleviate the excruciating socio-economic and infrastructural conditions of the people

Safe spaces for beneficiaries of a combination HIV prevention intervention for adolescent girls and young women in South Africa: access, feasibility, and acceptability

BackgroundSafe Spaces are a feature of combination HIV prevention interventions for adolescent girls and young women (AGYW) in South Africa. We investigated whether AGYW at risk for adverse sexual and reproductive health (SRH) outcomes accessed Safe Spaces that were part of an intervention, as well as their feasibility and acceptability.MethodsIn December 2020 to February 2021, as part of a process evaluation of a combination HIV prevention intervention, we randomly sampled 2160 AGYW intervention beneficiaries aged 15–24 years from 6 of the 12 intervention districts. We invited them to participate in a phone survey, with questions about their vulnerability to adverse SRH outcomes, and participation in intervention components including Safe Spaces. We examined factors associated with use of Safe Spaces using bivariate analyses and Pearson’s chi squared tests. We also conducted in-depth interviews with 50 AGYW beneficiaries, 27 intervention implementers, 4 health workers, 7 social workers, and 12 community stakeholders, to explore perceptions and experiences of the intervention. Thematic analysis of the qualitative data was performed.ResultsAt least 30 Safe Spaces were established across 6 districts. Five hundred fifteen of two thousand one hundred sixty sampled AGYW participated in the survey of whom 22.6% visited a Safe Space, accessing HIV testing (52.2%), mobile health services (21.2%) and counselling for distress (24.8%) while there. Beneficiaries of lower socioeconomic status (SES) were less likely to have visited a Safe Space, compared with those of higher SES (13.6% versus 25.3%; p < 0.01). Implementers described political, structural and financial challenges in identifying and setting up Safe Spaces that were safe, accessible and adequately-resourced, and challenges with AGYW not utilising them as expected. AGYW shared positive views of Safe Spaces, describing benefits such as access to computers and the internet, support with homework and job and education applications, and a space in which to connect with peers.ConclusionAGYW are attracted to Safe Spaces by educational and employment promoting interventions and recreational activities, and many will take up the offer of SRH services while there. The poorest AGYW are more likely to be excluded, therefore, an understanding of the obstacles to, and enablers of their inclusion should inform Safe Space intervention design.

Crowdsourcing to design a marketing package to promote a WHO digital mental health intervention among Chinese young adults

BackgroundDigital mental health is an emerging field that can leverage technology and mobile apps to deliver mental health treatment to populations in areas with limited mental health services. Despite widespread availability of these apps, uptake remains low. Enhanced marketing is necessary to increase public engagement. There is growing recognition that mental health intervention beneficiaries should be engaged in all phases of treatment development, adaptation, and delivery. Crowdsourcing – consulting the public to solve problems and sharing the solutions – can foster community-informed ideas for public health, but has yet been applied to digital mental health marketing. ObjectiveWith the goal of engaging potential intervention beneficiaries in digital mental health dissemination, the current project implemented a digital mental health crowdsourcing designathon for Chinese college students in Macao SAR, China and evaluated the feasibility of the contest and the products. The contest asked participants to design marketing packages for Step-by-Step, a scalable WHO digital mental health intervention focusing on depression. MethodsDesignathon participants, recruited from a global health class, were sorted into teams with balanced areas of expertise. Two judging panels – one of experts in relevant fields and another of Chinese college students – evaluated the marketing packages and selected finalists. The designathon was held in-person over four days and involved debriefing, workshops, a contest, and an awards ceremony. A parallel mixed-methods approach was applied, including qualitative feedback from judges and participants alongside quantitative data on participant satisfaction and depressive symptoms to enrich our understanding of the event. Additionally, based on judges' feedback given to participants, the communication packages of the contest were ranked. Results49 participants (8 teams of 6–7 members each) were involved in the designathon. Using a cutoff score of 10 on the Patient Health Questionnaire-9 (PHQ-9), 11.4% of participants had moderate or higher depressive symptoms. All teams successfully produced complete digital mental health marketing packages. Four finalists' packages were selected quantitatively with judges' scores and the top finalist's package was described by judges' comments as simple, thoughtful, and appealing, although not informative enough. Participants were overall satisfied with the designathon, but some mentioned that time was insufficient and that organization/instruction clarity could have been improved. ConclusionsThe designathon is a novel, feasible strategy to collect crowd input for the dissemination of a mental health intervention. Compared with traditional communication strategies, this bottom-up approach included and engaged potential intervention beneficiaries to take an active role in creating digital mental health marketing communication. Future contests should allow participants more time and reconsider aspects of event organization.

Tutor of Resilience: A Model for Psychosocial Care Following Experiences of Adversity.

This article describes a model for training service providers to provide interventions that build resilience among individuals who have experienced adversity. The Tutor of Resilience model emphasizes two distinct dimensions to training: (1) transforming service providers' perceptions of intervention beneficiaries by highlighting their strengths and capacity for healing; and (2) flexibly building contextually and culturally specific interventions through a five-phase model of program development and implementation. Tutor of Resilience has been employed successfully with child and youth populations under stress in humanitarian settings where mental health and psychosocial support professionals are required to design and deliver interventions that enhance resilience among vulnerable children.

Insights from the Implementation and Adoption of Community-Based Health Interventions

Abstract Effective implementation of health interventions is critical for maximum adoption and optimal health outcomes. This qualitative study assessed the differences in Community Health Club (CHC) implementation in villages using qualitative research methods. Villages in Rusizi district in Rwanda were purposively selected with high, medium, and low adoption rates. The results revealed that the traits and skills of intervention facilitators (providers or implementers) at the village level, the involvement of the head of the village in the CHC intervention activities, and the support supervision by the Community Environmental Health Officer from the health center may have contributed to high rates of adoption of the intervention. Poor community organization, mistrust, lack of equal consideration among intervention beneficiaries, and lack of skills and capacity for intervention facilitators may have contributed to the low rates of intervention adoption. The results of this study suggest the need for capacity building of implementers, local leaders, and supervisors for improved (1) skills to adapt to local contexts and maximize the intervention adoption, (2) involvement and participation of local leadership, and (3) support supervision, guidance, and close monitoring, respectively. for effective implementation and maximum adoption of CHC intervention.

Innovation for improved hygiene: testing a handwashing station that uses recycled water in the field.

Access to handwashing facilities is limited in cities in the Global South. On-site recycling of water can improve access to handwashing facilities in places that lack water and wastewater related infrastructure. A handwashing station prototype that uses recycled water was tested in real-life applications in Switzerland and South Africa, where it addresses both social and environmental goals. The transdisciplinary approach taken by the research team (a strategy where researchers from different disciplines work closely together with the users and beneficiaries of interventions) was a crucial factor in the acceptance of the handwashing station using recycled water.

Implementation outcomes of policy and programme innovations to prevent obstetric haemorrhage in low- and middle-income countries: a systematic review.

Globally, obstetric haemorrhage (OH) remains the leading cause of maternal mortality. Much of the associated mortality is ascribed to challenges surrounding deployment of innovations rather than lack of availability. In low- and middle-income countries (LMICs), where the burden is highest, there is a growing interest in implementation research as a means to bridge the 'know-do' gap between proven interventions and their reliable implementation at scale. In this systematic review, we identified and synthesized qualitative and quantitative data across the implementation outcomes of OH prevention innovations in LMICs using a taxonomy developed by Proctor et al. We also identified service outcomes for the included innovations, as well as implementation strategies and implementation facilitators and barriers. Eligible studies were empirical, focused on the implementation of OH prevention programmes or policies and occurred in an LMIC. Eight databases were searched. Two authors independently assessed studies for selection and extracted data; the first author resolved discrepancies. Narrative synthesis was used to analyse and interpret the findings. Studies were predominantly focused in Africa and on primary prevention. Interventions included prophylactic use of uterotonics (n = 7), clinical provider skills training (n = 4) and provision of clinical guidelines (n = 1); some (n = 3) were also part of a multi-component quality improvement bundle. Various barriers were reported, including challenges among intervention beneficiaries, providers and within the health system; however, studies reported the development and testing of practical implementation solutions. These included training and monitoring of implementers, community and stakeholder engagement and guidance by external mentors. Some studies linked successful delivery to implementation outcomes, most commonly adoption and acceptability, but also feasibility, penetration and sustainability. Findings suggest that innovations to prevent OH can be acceptable, appropriate and feasible in LMIC settings; however, more research is needed to better evaluate these and other under-reported implementation outcomes.

Absenteísmo de usuários

Introdução: O absenteísmo dos usuários aos serviços de saúde é um fenômeno que vem impactando a atenção à saúde. Objetivo: Identificar a evidência científica disponível sobre as possíveis causas do absenteísmo dos usuários aos serviços de saúde. Métodos: Este estudo analisou 34 publicações, classificadas em três unidades temáticas: barreiras do acesso; impacto dos serviços como determinante da saúde dos usuários; fatores condicionantes e facilitadores do acesso. Resultados: Enfrentar o absenteísmo exige a compreensão das desigualdades sociais, requer conhecimento sobre a organização dos serviços de saúde, dos determinantes sociais e das relações que ocorrem entre os grupos no contexto social. As principais razões para o absenteísmo são evitáveis e pode se beneficiar de intervenções para melhoria dos serviços de saúde. Conclusões: O conhecimento das barreiras e determinantes do acesso permite compreender as possíveis causas do absenteísmo e suas consequências, a fim de fundamentar a tomada de decisões que possibilitem a correção ou minimização de riscos e de prejuízos econômicos, na administração dos serviços públicos de saúde.

From intervention to interventional system: towards greater theorization in population health intervention research

BackgroundPopulation health intervention research raises major conceptual and methodological issues. These require us to clarify what an intervention is and how best to address it.This paper aims to clarify the concepts of intervention and context and to propose a way to consider their interactions in evaluation studies, especially by addressing the mechanisms and using the theory-driven evaluation methodology.Main textThis article synthesizes the notions of intervention and context. It suggests that we consider an “interventional system”, defined as a set of interrelated human and non-human contextual agents within spatial and temporal boundaries generating mechanistic configurations – mechanisms – which are prerequisites for change in health. The evaluation focal point is no longer the interventional ingredients taken separately from the context, but rather mechanisms that punctuate the process of change. It encourages a move towards theorization in evaluation designs, in order to analyze the interventional system more effectively. More particularly, it promotes theory-driven evaluation, either alone or combined with experimental designs.ConclusionConsidering the intervention system, hybridizing paradigms in a process of theorization within evaluation designs, including different scientific disciplines, practitioners and intervention beneficiaries, may allow researchers a better understanding of what is being investigated and enable them to design the most appropriate methods and modalities for characterizing the interventional system. Evaluation methodologies should therefore be repositioned in relation to one another with regard to a new definition of “evidence”, repositioning practitioners’ expertise, qualitative paradigms and experimental questions in order to address the intervention system more profoundly.

Urban young women's preferences for intervention strategies to promote physical and mental health preconception: A Healthy Life Trajectories Initiative (HeLTI).

This study aimed to qualitatively investigate young women's preferences for preconception intervention strategies to promote physical and mental health in a rapidly transitioning, urban setting. Four semi-structured focus group discussions were conducted with young women (n = 29, 18–24 years old) from Soweto, South Africa. Qualitative data were thematically analysed. Two main themes were identified: 1) challenges and needs of intervention beneficiaries; and 2) preferences for intervention strategies (content and delivery). The challenges participants mentioned could be classified as those relating to social pressure, identity, and socioeconomic circumstances. Mental health support appeared to be a greater need than physical health, and this featured in their preferences for intervention content, although a number of physical health topics were also mentioned (healthy eating and contraception). Participants had mixed preferences for intervention materials, ranging from printed to electronic and mobile resources. Their preferences for intervention activities ranged from educational sessions, to fun and interactive practical activities, and activities they could take home. Community health workers (CHWs) were the preferred agent of delivery for interventions, though participants emphasised the importance of CHWs having appropriate interpersonal skills and own life experience. Some women preferred one-on-one sessions with a CHW, while others preferred group sessions. While recognising the value of family sessions, young women were less enthusiastic about this approach. These findings provide valuable formative data for developing effective interventions to optimise young women's preconception health in urban Africa. These contextual realities should be acknowledged when addressing key physical and mental health issues facing young women.

From Herding to Farming under Adaptation Interventions in Southern Kenya: A Critical Perspective

Improving water supply for irrigable farming and livestock purposes in communities in Africa is an increasingly popular approach for community-based adaptation interventions. A widespread intervention is the construction of agro-pastoral dams and irrigation schemes in traditionally pastoral communities that face a drying climate. Taking the Maji Moto Maasai community in southern Kenya as a case study, this article demonstrates that water access inequality can lead to a breakdown of pre-existing social capital and former pastoral cooperative structures within a community. When such interventions trigger new water uses, such as farming in former pastoral landscapes, there are no traditional customary institutional structures in place to manage the new water resource. The resulting easily corruptible local water management institutions are a main consolidator of water access inequalities for intervention beneficiaries, where socio-economic standing often determines benefits from interventions. Ultimately, technological adaptation interventions such as agro-pastoral dams may result in tensions and a high fragmentation of adaptive capacity within target communities.

Territorial Conflicts, Agency and the Strategic Appropriation of Interventions in Kenya’s Southern Drylands

A number of scholars have noted that interventions, such as development programmes and climate change adaptation projects, that simplify complex social realities and thus lose sight of the relational dynamics beyond the target or beneficiary group, risk contributing to conflict. This article examines how a series of interventions in a particular dryland area in southern Kenya became embroiled in a long-running territorial conflict between the Loita Maasai (the beneficiary community) and their neighbours, the non-beneficiary Purko Maasai. Based on ethnographic research and by taking a historical perspective, it shows how Loita Maasai leaders systematically appropriated these outside interventions, used and reworked them with the strategic aim of stopping land loss to ongoing Purko encroachment. The analysis reveals two ways in which Loita leaders realized this: (a) by using interventions to stake out spatial claims to land; and (b) by capitalizing on the tendency of interventions to simplify local contexts. This article contributes to the debate on the linkages between intervention and conflict by highlighting the agency of intervention beneficiaries and showing that, through their actions, interventions may unwittingly reproduce and even aggravate existing conflicts.

Economic and Clinical Outcomes Resulting From the Stage 4 Chronic Kidney Disease Case Management Quality Improvement Initiative.

Purpose of Study:Chronic kidney disease (CKD) is a costly and burdensome public health concern. The goal of this study was to evaluate the impact on outcomes and utilization of a pilot program to identify and engage beneficiaries with CKD at risk for progression from Stage 4 to Stage 5.Primary Practice Settings:A quality improvement initiative was conducted to assess the impact of case management on costs and outcomes among 7,720 Cigna commercial medical beneficiaries with Stage 4 CKD enrolled in the United States between January 2012 and October 2012.Methodology and Sample:Claims data were analyzed to compare 3,861 beneficiaries randomized to receive condition-focused case management with 3,859 controls, with follow-up through July 2013. After using an algorithm to identify beneficiaries at highest risk of progression, a case management team implemented, among those assigned to the intervention, an evidence-based assessment tool, provided education and follow-up, engaged nephrologists and other providers, and conducted weekly rounds. Primary outcome measures were hospital admissions, emergency department visits, nephrologist visits, dialysis, arteriovenous (AV) fistula creation, and total medical costs. Analysis of variance techniques were used to test group differences.Results:As compared with controls, intervention beneficiaries were 12% more likely to have fistula creation (p = .004). Intervention beneficiaries were observed to have savings of $199 per member per month (PMPM), F = 23.05, p = .04. This difference equated to 6% lower total medical costs in the intervention group. Savings observed were derived half from improved in-network utilization and half from reduced hospital costs.Implications for Case Management Practice:The observed 12% increased rate of creation of AV fistulas and $199 (6%) decrease in PMPM cost between the intervention and control groups corresponded to a savings of more than $18 million in 2015 U.S. dollars (USD).On the basis of observation of substantial improvements in outcomes and cost savings, health plan administrators could better serve those at highest risk of progression by implementing focused case management.Our findings support the value of care coordination between nephrologists, providers, and health plan case managers in improving outcomes and reducing total medical costs among beneficiaries at risk for CKD progression from Stage 4 to Stage 5.

Access to modern fuels and satisfaction with cooking arrangements: Survey evidence from rural India

Subjective satisfaction is a central element of technology adoption, but scholars have not analyzed the determinants of households' satisfaction with their cooking arrangements. Drawing on an original survey of 8568 households across six Indian states, we uncover the predictors of such satisfaction. Households do not find firewood collection inconvenient, but they are dissatisfied if they have to travel long distance to purchase firewood. Among sub-components of subjective satisfaction, reduction in smoke, speed of cooking, and quality of meals dominate over others (difficulty, cost, and safety). Moreover, we identify access to LPG – a modern cooking fuel – as a strong and robust predictor of high subjective satisfaction, mostly through reduction in smoke and increase in speed of cooking. Rural households ascribe a lot of value to access modern cooking fuels that reduce indoor air pollution, and beneficiaries of interventions to improve such access would value it. Thus, efforts to reduce reliance on cooking with traditional biomass are not just paternalistic top-down interventions but contribute to significantly improve households' satisfaction with their cooking arrangements.

Impact of a telehealth and care management program for patients with chronic obstructive pulmonary disease.

Improving outcomes and health resource use for patients with chronic obstructive pulmonary disease (COPD) care is a priority for health systems. The Health Buddy Program, a content-driven telehealth system coupled with care management, is designed to enhance patient education, self-management, and timely access to care. To examine the effects of the Health Buddy Program on resource use among Medicare patients with COPD who participated in a Centers for Medicare and Medicaid Services demonstration project from 2006 to 2010. Medicare fee-for-service beneficiaries with COPD who enrolled in the intervention at two participating clinics were propensity-score matched to similar patients with COPD identified from a 5% random sample of Medicare patients. Difference-in-difference analyses descriptively compared the program's effect on quarterly healthcare resource use over the 3-year study period compared with baseline. Negative binomial models estimated the association of the program with healthcare resource outcomes adjusting for significant (P<0.05) baseline differences post matching. The effect of the Health Buddy Program on quarterly all-cause and respiratory-related hospital admissions, hospital admissions for COPD exacerbations, and all-cause emergency department use was assessed after matching. Intervention (n=619) and matched control subjects (n=619) had similar baseline characteristics after matching. The Health Buddy Program was associated with 23% lower quarterly all-cause hospital admissions and 40% lower quarterly respiratory-related hospital admissions compared with baseline for intervention beneficiaries versus control subjects. In subgroup analyses, patients who engaged in the intervention during the study period (n=247) demonstrated significantly lower quarterly hospital admissions for COPD exacerbations. The Health Buddy Program was not associated with reductions in quarterly emergency department use. Results were robust in analyses that adjusted for significant differences in baseline characteristics after matching. A content-driven telehealth system combined with care management has the potential to improve health outcomes in Medicare beneficiaries with COPD.

Peopling Global Health

The field of Global Health brings together a vastly diverse array of actors working to address pressing health issues worldwide with unprecedented financial and technological resources and informed by various agendas. While Global Health initiatives are booming and displacing earlier framings of the field (such as tropical medicine or international health), critical analyses of the social, political, and economic processes associated with this expanding field — an “open source anarchy” on the ground — are still few and far between. In this essay, we contend that, among the powerful players of Global Health, the supposed beneficiaries of interventions are generally lost from view and appear as having little to say or nothing to contribute. We make the case for a more comprehensive and people-centered approach and demonstrate the crucial role of ethnography as an empirical lantern in Global Health. By shifting the emphasis from diseases to people and environments, and from trickle-down access to equality, we have the opportunity to set a humane agenda that both realistically confronts challenges and expands our vision of the future of global communities.

Twelve Theses on the Impact of Humanitarian Intervention

Armed external intervention may sometimes be required to halt barbaric attacks on the vulnerable, but rebuilding political, economic and social order in the aftermath of an intervention is fraught with difficulty. Post-intervention problems may include coping with new and fractious actors, managing complex processes of change, addressing fundamental questions of political philosophy, coping with `spoilers' and low levels of trust, and avoiding inadvertent damage to the intervention's beneficiaries - all in situations where resources may be scarce and intervening powers at odds with each other. Interveners should strive to absorb the lessons of past interventions and master the complexities of the territory on which they propose to act. Patience and humility are sterling qualities in an intervening force, even where robust action is required. Adapting Montesquieu's advice, if one must intervene, one should do so with a trembling hand.