Complex Public Health Interventions Research Articles

5.E. Workshop: Complex public health interventions to increase Health Enhancing Physical Activity (HEPA)

5.E. Workshop: Complex public health interventions to increase Health Enhancing Physical Activity (HEPA)

Understanding the Importance of Context: A Qualitative Study of a Location-Based Exergame to Enhance School Childrens Physical Activity.

Many public health interventions are less effective than expected in ‘real life settings’, yet little work is undertaken to understand the reasons why. The effectiveness of complex public health interventions can often be traced back to a robust programme theory (how and why an intervention brings about a change in outcome(s)) and assumptions that are made about the context in which it is implemented. Understanding whether effectiveness (or lack thereof) is due to the intervention or the context is hugely helpful in decisions about whether to a) modify the intervention; b) modify the context; c) stop providing the intervention. Exergames–also known as Active Video Games or AVGS–are video games which use the player's bodily movements as input and have potential to increase physical activity in children. However, the results of a recent pilot randomised controlled trial (RCT) of a location-based exergame (FitQuest) in a school setting were inconclusive; no significant effect was detected for any of the outcome measures. The aim of this study was to explore whether the programme theory for FitQuest was correct with respect to how and why it would change children’s perceptions of physical activity (PA) and exercise self-efficacy in the school setting. A further aim was to investigate the features of the school setting (context) that may impact on FitQuest’s implementation and effectiveness. Qualitative data (gathered during the RCT) were gathered from interviews with teachers and children, and observation of sessions using FitQuest. Thematic analysis indicated that whilst children enjoyed playing the game, engaged with goal setting within the game context and undertook low to vigorous physical activity, there were significant contextual factors that prevented it from being played as often as intended. These included environmental factors (e.g. size of the playground), school factors (cancellations due to other activities), school technology policy (rules relating to mobile phone usage) and teacher factors (engagement with the intervention). A revised logic model for the FitQuest intervention indicates how both the design of exergame technology (intervention) and features of the school environment (context) could be improved to increase chances of effectiveness in the future.

Adapting, piloting and evaluating complex public health interventions: lessons learned from the Nurse-Family Partnership in Canadian public health settings.

The Nurse-Family Partnership (NFP) is a home-visit program for young and first-time, socially and economically disadvantaged mothers. Evidence from three United States randomized controlled trials (RCTs) on the effectiveness of this intervention at improving pregnancy outcomes, improving child health and development, and increasing maternal economic self-sufficiency is robust. However, the effectiveness of the NFP in Canada, with its different health and social care context, needs to be determined. The purpose of this article is to describe the complex process for moving the NFP from the research arena to full implementation in Canada. This process of evaluation in Canada includes (1) adapting the intervention; (2) piloting the intervention in small-scale feasibility and acceptability studies; and (3) conducting an RCT and process evaluation through a study called the British Columbia Healthy Connections Project (BCHCP). This large-scale evaluation also creates an opportunity to expand the NFP evidence base by conducting an additional study to examine potential biological mechanisms linking intervention and behavioural outcomes in children. Adaptation of the NFP home-visit materials is a continuous process. A pilot project determined that it was feasible to enrol eligible women into the NFP. This pilot also determined that, in Canada, it was most appropriate for public health agencies to implement the NFP and for public health nurses to deliver the intervention. Finally, the pilot showed that this intensive home-visit program was acceptable to clients, their family members and health care providers. Through the BCHCP, the next steps - the RCT and process evaluation - are currently underway. The BCHCP will also set the foundation for long-term evaluation of key public health outcomes in a highly vulnerable population of families.

Prospective evaluation of a complex public health intervention: lessons from an initial and follow-up cross-sectional survey of the tuberculosis strain typing service in England

BackgroundThe national tuberculosis strain typing service (TB-STS) was introduced in England in 2010. The TB-STS involves MIRU-VNTR typing of isolates from all TB patients for the prospective identification, reporting and investigation of TB strain typing clusters. As part of a mixed-method evaluation, we report on a repeated cross-sectional survey to illustrate the challenges surrounding the evaluation of a complex national public health intervention.MethodsAn online initial and follow-up questionnaire survey assessed the knowledge, attitudes and practices of public health staff, physicians and nurses working in TB control in November 2010 and March 2012. It included questions on the implementation, experience and uptake of the TB-STS. Participants that responded to both surveys were included in the analysis.Results248 participants responded to the initial survey and 137 of these responded to the follow-up survey (56% retention).Knowledge: A significant increase in knowledge was observed, including a rise in the proportion of respondents who had received training (28.6% to 67.9%, p = 0.003), and the self-rated knowledge of how to use strain typing had improved (‘no knowledge’ decreased from 43.2% to 27.4%).Attitudes: The majority of respondents found strain typing useful; the proportion that reported strain typing to be useful was similar across the two surveys (95.7% to 94.7%, p = 0.67).Practices: There were significant increases between the initial and follow-up surveys in the number of respondents who reported using strain typing (57.0% to 80.5%, p < 0.001) and the proportion of time health protection staff spent on investigating TB (2.74% to 7.08%, p = 0.04).ConclusionsEvaluation of a complex public health intervention is challenging. In this example, the immediate national roll-out of the TB-STS meant that a controlled survey design was not possible. This study informs the future development of the TB-STS by identifying the need for training to reach wider professional groups, and argues for its continuation based on service users’ perception that it is useful. By highlighting the importance of a well-defined sampling frame, collecting baseline information, and including all stakeholders, it provides lessons for the implementation of similar services in other countries and future evaluations of public health interventions.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2458-14-1023) contains supplementary material, which is available to authorized users.

The effect of a behaviour change intervention on the diets and physical activity levels of women attending Sure Start Children’s Centres: results from a complex public health intervention

ObjectivesThe UK government's response to the obesity epidemic calls for action in communities to improve people's health behaviour. This study evaluated the effects of a community intervention on dietary quality...

Logistics of Guinea worm disease eradication in South Sudan.

From 2006 to 2012, the South Sudan Guinea Worm Eradication Program reduced new Guinea worm disease (dracunculiasis) cases by over 90%, despite substantial programmatic challenges. Program logistics have played a key role in program achievements to date. The program uses disease surveillance and program performance data and integrated technical–logistical staffing to maintain flexible and effective logistical support for active community-based surveillance and intervention delivery in thousands of remote communities. Lessons learned from logistical design and management can resonate across similar complex surveillance and public health intervention delivery programs, such as mass drug administration for the control of neglected tropical diseases and other disease eradication programs. Logistical challenges in various public health scenarios and the pivotal contribution of logistics to Guinea worm case reductions in South Sudan underscore the need for additional inquiry into the role of logistics in public health programming in low-income countries.

Evaluation of the Tuberculosis Strain Typing Service (TB-STS) in England

BackgroundAfter increases in tuberculosis notification rates, the Chief Medical Officer's Tuberculosis Action Plan in 2004 led to the introduction of the national Tuberculosis Strain-Typing Service (TB-STS), using MIRU-VNTR typing, in England in 2010. In addition to reducing the proportion of individuals who are misdiagnosed as having tuberculosis, the TB-STS could reduce tuberculosis incidence by increasing the detection of latent infections and by accelerating diagnosis of active cases, through better-targeted cluster investigation. Complex public health interventions are often implemented without a prospective assessment. We describe a service-wide evaluation of a TB-STS using laboratory and contact tracing data, and mathematical modelling, to estimate effects on tuberculosis incidence and cost-effectiveness. MethodsThe proportion of false-positive Mycobacterium tuberculosis isolates, which had not been identified before strain-typing results became available, was estimated from laboratory data. The effect of cluster investigations on diagnostic delay (time between symptom onset and date of diagnosis) was estimated for pulmonary tuberculosis cases diagnosed in 2010–11. The contact tracing yield (the median number of individuals with tuberculosis infection or active disease identified per case), according to whether cases were in clusters that were investigated, was estimated from data from north central London and Leicester in 2011. With an age-structured deterministic compartmental model, we explored the effectiveness of the TB-STS in population groups in which the incidence is low (native UK population), medium (similar to the non-white UK-born population), and high (similar to the non-UK-born population). Cost-effectiveness was estimated for various scenarios, with use of outputs from the model and service assessment, costs of establishing and running the service, and estimated costs and quality-adjusted life-year (QALY) effects of tuberculosis infection and disease. FindingsFrom 11 059 isolates typed between June, 2010, and June, 2012, there were 30 incidents of false-positive M tuberculosis isolation, 17 (57%) of which had not been identified before strain-typing results were available. Cluster investigations had no significant effect on the diagnostic delay (median 85 days [IQR 47–155] vs 77 days [41–157]) or on contact tracing yield (mean number of cases with active tuberculosis 0·33, 95% CI 0·1 to 0·6 vs 0·2, −0·0 to 0·5) or latent infection (1·9, 0·3–3·2 vs 1·7, 0·8–2·5). Mathematical modelling suggested that increasing the proportion of infections that are detected would have little effect on tuberculosis incidence and the number of cases prevented in the native UK population. In medium-incidence or high-incidence settings, under base-case assumptions, increasing the proportion of infections detected by a small amount (eg, from 3% per year to 13% per year with strain typing) could lead to about an 11% reduction in tuberculosis incidence over 20 years, ranging between 4% and 12% for pessimistic and optimistic assumptions, respectively, relating to uptake and retention of preventive treatment. In medium-incidence settings and with all other factors remaining unchanged, reducing diagnostic delay by 1 week could lead to greater than 25% reductions in tuberculosis incidence over 20 years. These findings are sensitive to the assumed proportion of immigrants who enter the UK with tuberculosis. Under base case assumptions, the service was not estimated to be cost-effective over a 20-year period (£97 311 per QALY). InterpretationInsufficient baseline and post-implementation data limit direct estimation of public-health outcomes and interpretation of the model. Present models suggest that the TB-STS is not cost-effective. However, the TB-STS provides an invaluable resource for epidemiological and microbiological research and surveillance, informing national and local tuberculosis control efforts; targeting population-level interventions; and contributing to understanding molecular epidemiology in Europe and worldwide. FundingPublic Health England's TB Strain Typing Project Board. JM is funded by a University College London and Public Health England Impact Studentship. IA is funded by an NIHR Senior Research Fellowship.

Developing methods for locating and synthesising theory for application in public health: a pilot study

BackgroundDespite published work suggesting that public health interventions will probably be more effective when underpinned by relevant theory, this is often missing from their design and development. This absence might be because the theoretical published work is not easily accessible, because its sheer volume is overwhelming, or because the theories are not always clearly articulated. There is a need to develop ways of accessing and synthesising bodies of theory for use in public health. We use the area of health-related risk taking as an example and explore the feasibility of locating and synthesising sociological theories in this area. Sociological theories are underused in public health, but are necessary to help to shift the focus towards the social structures that affect behaviour, ensuring that responsibility for change is not placed solely on the individual. We aimed to search for sociological theories of health-related risk taking and to explore the feasibility of theory synthesis as an instrument for public health. MethodsWe hand searched the abstracts of all volumes of the journals Sociology of Health and Illness (volume 1, 1979, to May, 2012) and Social Science and Medicine (volume 1, 1982, to mid-June, 2012) and checked the references of selected papers for relevant publications. Papers were included if they were sociological, relevant to risk taking, and theoretical. After a method outlined by sociological theorist Jonathan Turner, we undertook a synthesis of four of the theories that were related in terms of their subject matter and theoretical perspective. The process of theory synthesis includes the following steps: (1) synthesis preparation, which involves clarifying theories, abstracting them to make them comparable, and extracting what is viewed as most plausible and useful to the question at hand; (2) synthesis, which is the systematic comparison of theories for points of convergence and divergence; and (3) synthesis refinement, which involves closer analysis of the theories with a view to the production of a more robust theory for practical application, including a clarification of causal processes. FindingsWe found 16 different theories that we grouped into seven broad categories according to their theoretical perspective: (1) theories that draw a link between culture and risk taking; (2) theories that conceptualise risk taking as social practice; (3) theories that regard risk taking as a response to dominant social forces; (4) situated rationality and social action theories that place risk taking within wider power relations; (5) the theory of habitus, which helps explain how patterns of risk taking persist over generations and according to social class; (6) theories that stress the positive functions of risk taking; and (7) theories that link serious risk taking with social exclusion. A synthesis of theories in this last category resulted in a new theoretical proposition: that serious and persistent risk taking occurs on the margins of mainstream society and might be related to powerlessness and a liminal social status. InterpretationA limitation of the study was that papers were not independently screened by two people and this shortcoming would need to be addressed in future studies. By suggesting that risk taking might have social causes and functions, the sociological theories form a valuable counterbalance to prevailing theoretical perspectives that focus on individual behaviour and, in so doing, have the potential to inform a broader range of public health interventions. Further work will explore the possibility of applying these methods on a larger scale and of incorporating the results of theory syntheses into logic models to provide a practical instrument for use in the design of complex public health interventions. FundingThe study was funded by DECIPHer, a UKCRC Public Health Research Centre of Excellence. Funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council (RES-590-28-0005), Medical Research Council, the Welsh Government, and the Wellcome Trust (WT087640MA), under the auspices of the UKCRC, is gratefully acknowledged.

OP73 How can we Develop More Effective Public Health Interventions?

BackgroundA number of recent trials and systematic reviews of public health interventions have had disappointing conclusions despite a major investment in trials. An elegant evaluation design to test a poorly...

Realist RCTs of complex interventions – An oxymoron

Bonell et al. discuss the challenges of carrying out randomised controlled trials (RCTs) to evaluate complex interventions in public health, and consider the role of realist evaluation in enhancing this design (Bonell, Fletcher, Morton, Lorenc, & Moore, 2012). They argue for a “synergistic, rather than oppositional relationship between realist and randomised evaluation” and that “it is possible to benefit from the insights provided by realist evaluation without relinquishing the RCT as the best means of examining intervention causality.” We present counter-arguments to their analysis of realist evaluation and their recommendations for realist RCTs.Bonell et al. are right to question whether and how (quasi-)experimental designs can be improved to better evaluate complex public health interventions. However, the paper does not explain how a research design that is fundamentally built upon a positivist ontological and epistemological position can be meaningfully adapted to allow it to be used from within a realist paradigm. The recommendations for “realist RCTs” do not sufficiently take into account important elements of complexity that pose major challenges for the RCT design. They also ignore key tenets of the realist evaluation approach.We propose that the adjective ‘realist’ should continue to be used only for studies based on a realist philosophy and whose analytic approach follows the established principles of realist analysis. It seems more correct to call the approach proposed by Bonell and colleagues ‘theory informed RCT’, which indeed can help in enhancing RCTs.

Pragmatisme et réalisme pour l’évaluation des interventions de santé publique

Forty years ago, Schwartz and Lellouch invented pragmatic clinical trials. Their proposal has not yet been fully espoused. This appears to be the case today also in the domain of public health interventions evaluation, where some still insist on the superiority of experimental methods. Yet evaluations of complex public health interventions are fraught with pitfalls for researchers. Most such interventions take place in natural experimental contexts, where they have no control over the context or the factors that modify implementation and influence the effects. Experimental approaches are, in these cases, not very appropriate, and yet decision makers want to be able to take decisions to improve them. This article presents our experience over the past 5years with evaluative research in two public health interventions. We wish to show how we conduct evaluations in practice using a pragmatic approach. The article is focused on elements that have not, to date, received much attention in the francophone literature: the evaluability assesment and intervention logic, research strategies reinforced particularly by mixed methods and time series, and the analysis of implementation fidelity and mechanisms that foster effectiveness. Because the pragmatic approach to evaluative research stresses the need for good understanding of context and uses reinforced methodological strategies, it allows for rigorous responses to evaluation questions raised by those implementing complex public health interventions. Thus, experimental approaches are not necessarily required to analyze the effectiveness of interventions.

Strengthening the rigour of population-wide, community-based obesity prevention evaluations.

The aim of the present study was to review the methodological literature regarding evaluation methods for complex public health interventions broadly and, based on such methods, to critically reflect on the evaluation of contemporary community-based obesity prevention programmes. A systematic review of the methods and community-based literature was performed by one reviewer. The review identified that there is considerable scope to improve the rigour of community-based obesity prevention programmes through: prospective trial registration; the use of more rigorous research designs, particularly where routine databases including an objective measure of adiposity are available; implementing strategies to quantify and reduce the risk of selective non-participation bias; the development and use of validated instruments to assess intervention impacts; reporting of intervention process and context information; and more comprehensive analyses of trial outcomes. To maximise the quality and utility of community-based obesity prevention evaluations, programme implementers and evaluators need to carefully examine the strengths and pitfalls of evaluation decisions and seek to maximise evaluation rigour in the context of political, resource and practical constraints.

What is complexity and what do you do with it? Reflections on use of controlled trials to assess complex public health interventions

BackgroundDebate about the appropriate means to assess the effects of complex public health interventions is very much ongoing, particularly the feasibility and value of randomised controlled trials. There has been little systematic investigation of complexity in studies of public health interventions, but an approach to evaluation that explicitly investigates the signs and sources of complexity in an intervention has the potential to increase understanding of why an intervention works or fails. We review the debate about how randomised controlled trials can accommodate complex interventions, how complexity can be investigated within the controlled trial framework, and what the added benefits of such an approach might be. We use the Well London cluster randomised trial as a case study. Case studyLocal adaptation is a commonly cited feature of complexity, as are complicated intervention delivery logistics and interactions between multiple intervention components. A key unresolved objection to the use of controlled trials for complex intervention evaluation is the reductionist conceptualisation of the intervention. The effectiveness component of the Well London trial necessarily treats this multiple-component, locally adapted, community engagement for health programme as simple, to allow valid causal inference. Although the trial includes quantitative community-level outcomes and examines interaction between the intervention and context, this analysis is in a subgroup model. Only the qualitative study nested within the trial directly addresses signs of complexity (synergies between intervention components, phase changes, unexpected outcomes). We propose that the notion of an intervention as simple or complex is dictated by the research question. From this view, although the effectiveness component of a trial treats the intervention as simple, and as such could be seen as overly reductionist, it is not theoretically inconsistent for an assessment to include some additional components investigating aspects of complexity. Additional methods could be easily accommodated, both quantitative and qualitative, including collection of outcome and exposure data continuously throughout the intervention period from a subcohort of study participants; diaries and other ongoing reflective documentation by community members and practitioners delivering the intervention; and social network analysis. Logic models play a central part in identification of potential unexpected outcomes and sources of complexity for investigation. However, methods for logic model development must accommodate non-linear aspects of community engagement interventions to be useful. InterpretationThe benefit of a focus on complexity in the controlled trial framework is to provide rich data about how the intervention interacts with context to assess transferability and explain the findings of the effectiveness component, whether they are positive, null, or negative. The knowledge produced will expand the comparatively sparse basic science evidence base underpinning upstream, preventive public health interventions, which do not receive developmental funding akin to pharmaceutical interventions, to understand in detail how the intervention takes effect before an effectiveness trial. Complexity is important to consider in the process of development of research questions with relevant stakeholders. Consideration of complexity at that stage provides a less reductionist way of thinking about public health interventions and the social systems within which they exist, motivating selection of different research questions and, importantly, different outcomes for the study. FundingWellcome Trust (grant 083679/Z/07/Z).

The Devon Active Villages Evaluation (DAVE) trial: study protocol of a stepped wedge cluster randomised trial of a community-level physical activity intervention in rural southwest England.

BackgroundAlthough physical inactivity has been linked with numerous chronic health conditions and overall mortality, the majority of English adults report doing insufficient physical activity. To increase population physical activity levels, researchers have called for more community-level interventions. To evaluate these complex public health interventions, innovative study designs are required. This study protocol describes Devon Active Villages, a community-level intervention providing physical activity opportunities to 128 rural villages in southwest England, and the methods used to evaluate its effectiveness in increasing physical activity levels.Methods/DesignA stepped wedge cluster randomised trial will be used to evaluate whether Devon Active Villages leads to increased physical activity levels in rural communities. Community engagement will help tailor activity programmes for each village; communities will then be supported for a further twelve months. The intervention will be delivered over four periods, each lasting twelve weeks. Data collection consists of a postal survey of a random sample of adults aged 18 years and over, at baseline and after each of the four intervention periods. The questionnaire includes questions on participant demographics, physical activity behaviour, local environment characteristics, awareness of local activity programmes, and psychosocial factors. Based on detecting an increase in the proportion of people who meet physical activity guidelines (from 25% to 30%), at least ten respondents are needed from each of the 128 villages at each stage (80% power at the 5% level of significance). Anticipating a 20% response rate, 6,400 questionnaires will be sent out at each stage (i.e., 50 surveys to each village). Using data from all five periods, a comparison of study outcomes between intervention and control arms will be performed, allowing for time period (as a fixed effect) and the random effect induced by correlation of outcomes (clustering) within villages.DiscussionThis paper describes the use of a stepped wedge cluster randomised trial to evaluate a complex, community-level physical activity intervention in an under-studied population of adults in rural communities in southwest England. The study addresses gaps in the current literature by providing new insights into physical activity levels in this population.Trial Registration NumberCurrent Controlled Trials ISRCTN37321160

Assessing the evaluability of complex public health interventions: Five questions for researchers, funders and policymakers

BackgroundGovernment policies and programmes to improve public health can often be regarded as complex interventions, in that they typically involve the flexible or tailored implementation of multiple interacting activities in...

Assessing the evaluability of complex public health interventions: five questions for researchers, funders, and policymakers.

Evidence to support government programs to improve public health often is weak. Recognition of this "knowledge gap" has led to calls for more and better evaluation, but decisions about priorities for evaluation also need to be addressed in regard to financial restraint. Using England's Healthy Community Challenge Fund as a case study, this article presents a set of questions to stimulate and structure debate among researchers, funders, and policymakers and help make decisions about evaluation within and between complex public health interventions as they evolve from initial concept to dissemination of full-scale intervention packages. This approach can be used to identify the types of knowledge that might be generated from any evaluation, given the strength of evidence available in response to each of five questions, and to support a more systematic consideration of resource allocation decisions, depending on the types of knowledge required. The principles of this approach may be generalizable, and should be tested and refined for other complex public health and wider social interventions.

Evaluation design for a complex intervention program targeting loneliness in non-institutionalized elderly Dutch people.

BackgroundThe aim of this paper is to provide the rationale for an evaluation design for a complex intervention program targeting loneliness among non-institutionalized elderly people in a Dutch community. Complex public health interventions characteristically use the combined approach of intervening on the individual and on the environmental level. It is assumed that the components of a complex intervention interact with and reinforce each other. Furthermore, implementation is highly context-specific and its impact is influenced by external factors. Although the entire community is exposed to the intervention components, each individual is exposed to different components with a different intensity.Methods/DesignA logic model of change is used to develop the evaluation design. The model describes what outcomes may logically be expected at different points in time at the individual level. In order to address the complexity of a real-life setting, the evaluation design of the loneliness intervention comprises two types of evaluation studies. The first uses a quasi-experimental pre-test post-test design to evaluate the effectiveness of the overall intervention. A control community comparable to the intervention community was selected, with baseline measurements in 2008 and follow-up measurements scheduled for 2010. This study focuses on changes in the prevalence of loneliness and in the determinants of loneliness within individuals in the general elderly population. Complementarily, the second study is designed to evaluate the individual intervention components and focuses on delivery, reach, acceptance, and short-term outcomes. Different means of project records and surveys among participants are used to collect these data.DiscussionCombining these two evaluation strategies has the potential to assess the effectiveness of the overall complex intervention and the contribution of the individual intervention components thereto.

„Gesunder Niederrhein … gegen den Schlaganfall“: Konzept und Umsetzung eines intersektoralen Public Health Programms 2003–2008

When the Public Health Service Act of North Rhine-Westphalia (OGDG-NRW) came into effect local health conferences (KGK) were established in both rural and urban districts. These conferences are designed to optimize medical and social healthcare at the local level. In 2001 KGK managers from six neighbouring districts founded the Network Healthy Lower Rhine. From 2003 to 2008 this network was able to implement the "Healthy Lower Rhine ... against Stroke" programme. The initiative primarily aims at improving community knowledge of stroke with regard to 1) proper action ("Stroke is a medical emergency, so call the emergency number 112!") and 2) stroke warning signs. Eventually these steps are intended 3) to reduce prehospital delays. Before the program started a project plan was developed including evaluation approaches. The central elements of the concept include local health targets, intersectoral collaboration and networking, 5-year programme duration, social marketing and a communication strategy. Initially, a needs assessment was conducted using local expert panels, surveys on community knowledge, and clinical data sampling to assess healthcare quality. Subsequently, a package of measures with a "two-level implementation model" was prepared. Normative evaluation consisted of self-reflection within the network-team. The summative evaluation was based on two approaches: surveys on community knowledge of stroke (city of Düsseldorf and district of Wesel) as well as data sample collection in hospitals on health care quality. The central elements of the concepts were implemented. Community surveys revealed similar deficits in community knowledge of stroke in the city of Dusseldorf (2000 and 2004) and in the district of Wesel (2002 and 2008). Knowledge of proper action (call 112 in case of stroke) significantly improved in the Dusseldorf community from 32.5% of correct statements in 2000 to 50.6% correct answers in 2004 and, finally, in 2008 to 69% correct answers in the Wesel district. Hospitals in the district of Wesel collected three-month samples of data on prehospital times in 2003 (before the initiative was started) and in 2005. There was no significant change: the portion of 28% of patients being hospitalized within a three-hour window after the onset of stroke symptoms remained unchanged. Due to medical progress and demographic changes stroke remains a paramount issue of public health in Germany. With its programme "Healthy Lower Rhine ... against Stroke" the Network Healthy Lower Rhine provides a strategy for launching and implementing a complex and intersectoral public health intervention.

Wirksamkeit und Nutzen eines Screeningverfahrens zur Identifikation von rehabilitationsbedürftigen Personen mit Diabetes mellitus Typ 2: eine randomisierte, kontrollierte Evaluationsstudie unter Versicherten der Hamburg Münchener Krankenkasse

In Germany, medical rehabilitation has to be initiated by the members of health insurances. This often leads to delays in the application for and provision of rehabilitation services. Within a randomised controlled trial, a statutory health insurance evaluated a programme aimed at the prevention of activity limitations and restrictions of social participation in patients with type 2 diabetes. Firstly, potential persons with type 2 diabetes were identified. Secondly, their need for a medical rehabilitation was screened using a postal questionnaire. Thirdly, eligible participants were advised to apply for a medical rehabilitation. Potential study participants were identified by the health insurance via diabetes-specific data on hospital stays, work disability and medical prescriptions. Eligible persons were asked for written informed consent and received a screening questionnaire assessing their need for a medical rehabilitation. Respondents indicating need for a rehabilitation according to the algorithm were randomly allocated to an intervention group (IG) or control group (CG). The IG was actively advised to apply for a medical rehabilitation together with information about their individual risks; CG members received usual care. Twelve months after baseline the participants completed a postal follow-up questionnaire on social participation (primary outcome) and subjective health status (secondary outcome). In addition, the health insurance provided data on hospital treatment and sick leave (cases, days). Of 471 insurants with type 2 diabetes who gave written informed consent, the algorithm identified 223 cases with a rehabilitation need. The follow-up questionnaire was completed by 84.5% (IG: n=91, CG: n=93). Although the attendance in medical rehabilitation was low (IG: 25%), an intention to treat analysis showed significant advantages for the IG members compared to the CG (e.g., reduced body mass index, increased disease knowledge, reduced depressive mood and eating disorders). The IG members seemed to benefit at least slightly from the procedure carried out (screening plus recommendation). As in previous studies, the feasibility of randomised controlled trials to evaluate a complex public health intervention was demonstrated.

Vouchers for scaling up insecticide-treated nets in Tanzania: Methods for monitoring and evaluation of a national health system intervention

BackgroundThe Tanzania National Voucher Scheme (TNVS) uses the public health system and the commercial sector to deliver subsidised insecticide-treated nets (ITNs) to pregnant women. The system began operation in October 2004 and by May 2006 was operating in all districts in the country. Evaluating complex public health interventions which operate at national level requires a multidisciplinary approach, novel methods, and collaboration with implementers to support the timely translation of findings into programme changes. This paper describes this novel approach to delivering ITNs and the design of the monitoring and evaluation (M&E).MethodsA comprehensive and multidisciplinary M&E design was developed collaboratively between researchers and the National Malaria Control Programme. Five main domains of investigation were identified: (1) ITN coverage among target groups, (2) provision and use of reproductive and child health services, (3) "leakage" of vouchers, (4) the commercial ITN market, and (5) cost and cost-effectiveness of the scheme.ResultsThe evaluation plan combined quantitative (household and facility surveys, voucher tracking, retail census and cost analysis) and qualitative (focus groups and in-depth interviews) methods. This plan was defined in collaboration with implementing partners but undertaken independently. Findings were reported regularly to the national malaria control programme and partners, and used to modify the implementation strategy over time.ConclusionThe M&E of the TNVS is a potential model for generating information to guide national and international programmers about options for delivering priority interventions. It is independent, comprehensive, provides timely results, includes information on intermediate processes to allow implementation to be modified, measures leakage as well as coverage, and measures progress over time.