Multiple Intervention Program Research Articles

Using participatory videos in understanding farmers experiences with climate smart agricultural practices: reflections from Ghana

Climate-smart agriculture (CSA) has gained traction as one of the effective strategies in tackling the climate crisis. Many CSA practices have been promoted by development agencies to smallholder farmers based on the assumption that farmers would adopt these innovations for their potential benefits. However, the adoption of CSA practices in Ghana and much of Africa remains low and decision making and on-farm innovation processes are poorly understood. This study seeks to provide empirical and participatory insight into how smallholder farmers innovate. Based on a novel application of a participatory video methodology, in farming communities in the Upper West Region of Ghana, that have been exposed to multiple CSA intervention programmes, the paper analyses farmers’ own self-curated accounts of experiences with CSA innovation. The findings show that farmer’s motivation to adopt CSA innovations is driven by their concerns for food security, economic gains, and the environmental impact of climate change on their farming activities and livelihood. The study reveals a mismatch between the CSA technologies and practices advanced by the development agencies and what farmers perceive as relevant and important in addressing their farming challenges. In particular, the findings show that in a pool of more than 12 CSA technologies and practices that had been promoted through three donor-driven intervention programmes in the communities, farmers selected less labour intensive, less costly, and CSA technologies and practices that fitted to their current farming practices and the local context. Agricultural extension agents served as an important information source on the CSA innovation and their practical implementation and farmers’ social groups played a crucial role in facilitating learning about the CSA technologies and practices. There is the need to integrate farmers voices using innovative methodologies such as participatory videos to better understand farmers’ experiences in the innovation process which will help inform the design of effective interventions and promote adoption of innovations aimed at enhancing the productivity of smallholder farmers and reducing environmental impacts in African food systems. By focusing on the innovations that farmers perceive as beneficial and adaptable to their local contexts, development organizations can use their resources more efficiently and promote adoption of contextually appropriate CSA innovations.

Perinatal interventions to reduce the severity of postpartum depression: A narrative review

Postpartum depression (PPD) is a mental disorder that can affect mothers and their families, with symptoms of fatigue, mood swings, frequent anger for no reason, and excessive worry for the baby. Several studies regarding interventions that can be given to postpartum women with PPD have been carried out. The purpose of this review is to assess evidence on the effectiveness of a broad range of perinatal interventions to reduce the severity of PPD. The review of the literature has been done through PubMed, for papers with Randomized Control Trial (RCT) design published in 2012-2021. The approach was to explore quantitative parameters which is the EPDS score. More than 300 papers were identified, but only 6 studies met the inclusion criteria. A narrative review was conducted due to the studies' significant heterogeneity. Six studies reported a decrease in EPDS score. Six interventions have been identified to reduce the severity of PPD, they are exercise, psychological intervention, telephone-based Cognitive Behavioral Therapy (CBT), iBA (internet Behavioral Activation), application-based Cognitive Behavioral Therapy (CBT) and psychoeducation. This review suggests that multiple intervention program may lead to better outcomes in terms of client’s satisfaction. There is also some indication that psychoeducation support Maternal Parental Self-efficacy (MPSE) and social support besides EPDS.

Effects of a Multiple-Intervention Program on the Depressive Tendencies, Social Support, and Life Satisfaction of Older Adults in Taiwan

ABSTRACT Purpose This study evaluated the effectiveness of a multiple-intervention program (MIP) on the life satisfaction, social support, and depressive tendencies of older adults. Design A cross-sectional, pretest-posttest design involving a questionnaire survey was adopted. Methods Thirty-seven older adults were recruited from 2 daycare centers for an 8-week MIP comprising 60-min sessions conducted once a week. The questionnaire comprised the Short Portable Mental Status Questionnaire, Geriatric Depression Short Form-15 (GDS-SF15), Life Satisfaction Scale (LSS), and Inventory of Social Support Scale (ISSB). Findings The participants’ average GDS-SF15 score decreased considerably (by 35.3%), their average ISSB score increased from 61.9% to 80.9%, and their average LSS score increased from 48% to 64%. Conclusions The outcomes for depressive tendencies, social support, and life satisfaction were measured before and after the intervention, and the participants successfully engaged in the MIP throughout its duration and exhibited improvement. The MIP can serve as a basis for planning group activities for older adults. Clinical Evidence The MIP benefits older adults at daycare centers. Incorporating multiple activities into daily care can help increase the diversity, uniqueness, and innovativeness of a daycare center.

Preventing pressure injury in open-heart surgical patients: A systematic review.

Cardiac surgical patients are highly prone to developing surgery-related Pressure injuries (PIs). Prevention of PIs is an important patient safety priority in healthcare settings and patients care. So the aim of this study is to detect the effectiveness of prevention strategies to decrease PIs prevalence and incidence in patients undergoing open heart surgery. We identified studies through Web of Science, Scopus, PubMed, Cochrane, and ProQuest databases from inception through September 2022 with restrictions on the English language. Cochrane RoB 2, JBI, and NIH checklist were carried out as critical appraisal Tools to investigate the studies risk of bias. Finally, 10 studies with a total sample No. 1348, which fulfilled eligibility criteria were included in final systematic review. Most common interventions investigated in included studies were addressing impairments skin care which included the use of multilayer silicone foam, Care bundle and multiple intervention programs, alternative head inflatable pads, pressure-reducing foam mattresses, and electric bed frames as the effective PIs Prevention (PIP) strategies. While repositioning is one of the important causes mentioned in most PIP protocols, there was not adequate evidence to recommend any special turning regimens for PIP. Given current evidence, multilayer silicone foam, Care bundle and multiple intervention programs, alternative inflatable head pads, pressure-reducing foam mattresses, and electric bed frames are effective strategies to prevent pressure ulcers. Further investigations are needed to specify the cost-effectiveness of mentioned strategies and RCTs to determine other PIP strategies such as repositioning and mobilization, nutritional supplementation, creams, and co-interventions effects.

Realist Evaluation of the "Abiye" Safe Motherhood Initiative in Nigeria: Unveiling the Black-Box of Program Implementation and Health System Strengthening.

Realist evaluation studies have spanned different aspects of medicine, especially in the field of public health. However, very few of these studies explicitly detailed how program implementation triggered outcomes that could strengthen understanding of its effect on Health System Strengthening in specific settings. In low- and middle-income countries, like Nigeria, there is a paucity of realist evaluation studies, despite the implementation of multiple intervention programs and projects in these countries. This article is aimed at unveiling the black-box of program implementation and Health System Strengthening of the "Abiye" Safe Motherhood Program in Ondo State, Nigeria. Specifically, it identified the role of contextual factors in the "Abiye" program in Ondo State, determined the mechanisms that facilitated or constrained outcomes of the "Abiye" program, and developed a Context Mechanism Outcome (CMO) Configuration from which a Middle Range Theory (MRT) can be framed. This was qualitative research structured along with the realist domains (Context, Mechanism, and Outcome). The Initial Program Theory was validated by the qualitative study, after which a new MRT was developed. The study population comprised key stakeholders, secondary stakeholders, and primary stakeholders in the Abiye safe motherhood program. Data was collected through 10 key informant interviews, 28 in-depth interviews, and six focus group discussions sessions. Thematic analysis was used to analyze all the qualitative data collected, and seven themes with 19 subthemes emerged in the study. We identified 13 contextual factors under five principal areas, with most of the factors playing enabling roles, some playing inhibitory roles, while very few played both roles. We elicited eight mechanisms, and some of these facilitated the outcomes, while some constrained the outcomes of the program. Health system strengthening was a key feature of the outcome of the program. We developed a middle-range theory based on the 6 CMO configurations we elicited from the study. Realist evaluation is an iterative process that looks beyond the surface to generate evidence. By applying the realist approach, we generated pieces of evidence that can be adapted for policymaking in public health interventions in LMIC.

Perspective: When the cure might become the malady: the layering of multiple interventions with mandatory micronutrient fortification of foods in India

When public health programs with single nutrients are perceived to have a poor impact on the target health outcome, the policy response can be to supply more, by layering additional mandatory programs upon the extant programs. However, we argue for extreme caution, because nutrients (like medicines) are beneficial in the right dose, but potentially harmful when ingested in excess. Unnecessary motivations for the reactionary layering of multiple intervention programs emerge from incorrect measurements of the risk of nutrient inadequacy in the population, or incorrect biomarker cutoffs to evaluate the extent of nutrient deficiencies. The financial and social costs of additional layered programs are not trivial when traded off with other vital programs in a resource-poor economy, and when public health ethical dilemmas of autonomy, equity, and stigma are not addressed. An example of this conundrum in India is the perception of stagnancy in the response of the prevalence of anemia to the ongoing pharmacological iron supplementation program. The reaction has been a policy proposal to further increase iron intake through mandatory iron fortification of the rice provided in supplementary feeding programs like the Integrated Child Development Services and the School Mid-Day Meal. This is in addition to the ongoing pharmacological iron supplementation as well as other voluntary iron fortifications, such as those of salt and manufactured food products. However, before supplying more, it is vital to consider why the existing program is apparently not working, along with consideration of the potential for excess intake and related harms. This is relevant globally, particularly for countries contemplating multiple interventions to address micronutrient deficiencies. Supplying more by layering multiple nutrient interventions, instead of doing it right, without thoughtful considerations of social, biological, and ethics frameworks could be counterproductive. The cure, then, might well become the malady.

Global burden of medication non-adherence in chronic obstructive pulmonary disease (COPD) and asthma: a narrative review of the clinical and economic case for smart inhalers.

Medication non-adherence to asthma and chronic obstructive pulmonary disease therapy poses a significant burden for patients and societies. Non-adherence encompasses poor initiation, implementation (including poor inhalation technique) and non-persistence. Globally, non-adherence is associated with poor clinical outcomes, reduced quality of life and high healthcare and societal costs. Costs are mainly caused by excess hospitalizations and impaired work productivity. Multiple intervention programs to increase adherence in patients with asthma and chronic obstructive pulmonary disease have been conducted. However, these intervention programs are generally not as effective as intended. Additionally, adherence outcomes are mostly examined with non-objective or non-granular measures (e.g., self-report, dose count, pharmacy records). Recently developed smart inhalers could be the key to objectively diagnose and manage non-adherence effectively in patients with asthma and chronic obstructive pulmonary disease. Smart inhalers register usage of the inhaler, record time and date, send reminders, give feedback about adherence and some are able to assess inhaler technique and predict exacerbations. Still, some limitations need to be overcome before smart inhalers can be incorporated in usual care. For example, their cost-effectiveness and budget impact need to be examined. It is likely that smart inhalers are particularly cost-effective in specific asthma and chronic obstructive pulmonary disease subgroups, including patients with asthma eligible for additional GINA-5 therapy (oral corticosteroids or biologics), patients with severe asthma in GINA-5, patients with asthma with short-acting beta2 agonists overuse, patients with asthma and chronic obstructive pulmonary disease with frequent exacerbations and patients with asthma and chronic obstructive pulmonary disease of working-age. While there is high potential and evidence is accumulating, a final push seems needed to cost-effectively integrate smart inhalers in the daily management of patients with asthma and chronic obstructive pulmonary disease.

Academic Success for Culturally and Linguistically Diverse Nursing Students: An Integrative Review.

Culturally and linguistically diverse (CALD) students are at increased risk for attrition from prelicensure nursing programs. The literature clearly describes the struggles of CALD nursing students, and interventions that have increased student satisfaction and feelings of belonging. There is less evidence for interventions that correlate with academic outcomes. This integrative review sought to identify studies with an intervention and evaluation of an academic outcome for CALD nursing students. An integrative review was done according to the methodology described by Whittemore and Knafl. Two reviewers evaluated literature from 2000 to 2019 and identified 11 articles for analysis. Evidence based strategies to support CALD nursing student academic success include formal educational interventions, linguistic modification of test items, peer support, and multiple intervention programs. This review identified evidence-based strategies to support CALD nursing student success and made recommendations for nursing research and education. [J Nurs Educ. 2020;59(10):551-556.].

Clustering of lifestyle risk behaviours and its determinants among school-going adolescents in a middle-income country: a cross-sectional study

BackgroundLifestyle risk behaviours such as smoking, alcohol consumption, physical inactivity, sedentary behaviour and low fruit/vegetable intake have been identified as the major causes of chronic diseases. Such behaviours are usually instigated in adolescence and tend to persist into adulthood. Studies on the clustering of lifestyle risk behaviours among adolescents are scarce, particularly in developing countries. Therefore, the present paper aimed to determine the clustering of lifestyle risk behaviours and its determinants among school-going adolescents in Malaysia.MethodsData were extracted from a cross-sectional study, the Malaysian Adolescent Health Risk Behaviour (MyAHRB) study, which was conducted from May to September 2013 across 11 states in Peninsular Malaysia. A two-stage proportionate-to-size sampling method was employed to select a total of 3578 school-going adolescents aged 16–17 years from 20 selected schools in urban and rural settlements, respectively. The MyAHRB study adopted a set of self-administered questionnaires adapted from the Global School-based Student’s Health Survey (GSHS) and the Youth Risk Behaviour Surveillance.ResultsThe results from the analysis of 2991 school-going adolescents aged 16–17 years showed that 16 (in boys) and 15 (in girls) out of 32 combinations of lifestyle risk behaviours clustered. Girls (aOR 2.82, 95% CI: 2.32–3.43) were significantly more likely to have clustered risk behaviours than boys; however, no significant associated factors were observed among girls. In contrast, boys of Malay descent (aOR 0.64, 95% CI: 0.46–0.89) or boys who had at least three friends (aOR 0.65, 95% CI: 0.43–0.99) were less likely to engage in multiple risk behaviours.ConclusionThe present study demonstrated the clustering of multiple risk behaviours that occurred in both genders; these results suggest that multiple behaviour intervention programmes, instead of programmes based on siloed approaches, should be advocated and targeted to the high-risk sub-populations identified in the present study.

Effectiveness on hospital‐acquired pressure ulcers prevention: a systematic review

The effective approach on pressure ulcer (PU) prevention regarding patient safety in the hospital context was evaluated. Studies were identified from searches in EBSCO host, PubMed, and WebofScience databases from 2009 up to December 2018. Studies were selected if they were published in English, French, Portuguese, or Spanish; incidence of PUs was the primary outcome; participants were adults (≥18 years) admitted in hospital wards and/or units. The review included 26 studies. Studies related to prophylactic dressings applied in the sacrum, trochanters, and/or heels, education for health care professionals, and preventive skin care and system reminders on-screen inpatient care plan were effective in decreasing PUs. Most of the studies related to multiple intervention programmes were effective in decreasing PU occurrence. Single interventions, namely support surfaces and repositioning, were not always effective in preventing PUs. Repositioning only was effective when supported by technological pressure-mapping feedback or by a patient positioning system. Risk-assessment tools are not effective in preventing PUs. PUs in the hospital context are still a worldwide issue related to patient safety. Multiple intervention programmes were more effective in decreasing PU occurrence than single interventions in isolation. Single interventions (prophylactic dressings, support surfaces, repositioning, preventive skin care, system reminders, and education for health care professionals) were effective in decreasing PUs, which was always in compliance with other preventive measures. These results provide an overview of effective approaches that should be considered when establishing evidence-based guidelines to hospital health care professionals and administrators for clinical practice effective in preventing PUs.

Struggling With Reciprocity and Compassion: Mentoring Pregnant and Parenting Mothers Experiencing Vulnerability.

Transitioning from pregnancy to parenthood is particularly challenging for women living with low income and experiencing social isolation, mental illness, addiction, and/or family violence. The purpose of this qualitative study was to evaluate one component of Welcome to Parenthood, a two-generation multiple intervention program including neuroscience-based parenting education, kin and non-kin mentorship, and an engagement tool (baby kit). From late pregnancy to 2 months postpartum, mentors kept a journal regarding their experiences of mentoring mothers experiencing vulnerability. We engaged in a modified constructivist grounded theory to explore hand-written text from the journals. The core category, Struggling with Reciprocity and Compassion, influenced processes of Becoming a Mentor. Mentoring mothers experiencing vulnerability was both challenging and rewarding, requiring an inordinate amount of physical, social, emotional, and economic resources. To foster maternal mental health and infant development, pregnant and parenting women experiencing vulnerability could benefit from long-term reciprocal and compassionate mentoring.

Effectiveness of a multiple intervention programme for the prevention of falls in older adults persons from a University of the Third Age

Abstract Objective: To evaluate the effectiveness of a multiple intervention programme for the prevention of falls in older adults from a University of the Third Age (U3A). Method: A quasi-experimental, non-controlled, longitudinal and quantitative study was performed. 69 older adults were allocated into three groups: Control (CG), Physical Exercise (PEG) and Multiple Intervention (MIG). The instruments/tests used were: sociodemographic questionnaire, Geriatric Depression Scale (15-items), Mini-Mental State Examination, Timed-Up and Go (TUG), Sit-to-Stand and Hand-Grip Strength, Falls Efficacy Scale-International and Falls Risk Awareness Questionnaire (FRAQ).The PEG and MIG groups underwent physical training (walking, muscular resistance, and balance) for 16 weeks (2x/week, 60 min/session). In the same period, the MIG also participated in educational sessions (1x/week, 60min/session). Covariance analysis was used for group comparisons. The effect size of the interventions was also calculated. The level of significance was set at p<0.05. Results: 51 older adults (67±6.2 years and 76.3% women), of whom 15 were in the CG, 20 in the PEG and 16 in the MIG, concluded the study. TUG time in both intervention groups was reduced, but FRAQ score improved in the MIG only. Both interventions had a small effect on TUG time, while multiple intervention had a large effect on FRAQ. Conclusion: Multiple intervention brought additional benefits to the older adults from this U3A. In addition to improving balance, the older adults who underwent the multiple intervention increased their knowledge about risk factors for falls.

Investigation of characteristics of residents in RCHEs associated with MRSA colonization after implementation of infection control training program

Background: Residential care homes for the elderly (RCHEs) are considered potential reservoirs for transmission of Methicillin-resistant Staphylococcus aureus (MRSA). Infection control strategies have been introduced in RCHEs to curb the spread of MRSA. However, the effectiveness of these strategies in reducing MRSA is questionable. MRSA has remained prevalent in economically well-developed regions such as UK and the US despite the implementation of multiple intervention programs. We aim to investigate the characteristics of residents associated with MRSA colonization after implementation of common infection control strategies. Methods & Materials: Residents from selected RCHEs in Kwai Tsing and Tsuen Wan district in New Territories West, Hong Kong were recruited from March 2011 to April 2012. They were interviewed about their health condition and nasal specimens for MRSA screening twice in the study period, with 2-13 months apart. Additional wound specimens were also collected if wounds were identified. Infection control intervention was represented by healthcare staff training and education in the study RCHEs between two screening tests. We defined subjects as being colonized with MRSA if either nasal or wound specimen was tested positive. A multivariable random-effect regression model on follow-up MRSA colonization status was applied. Results: A total of 1832 residents from 32 RCHEs were recruited. The overall point prevalence of MRSA colonisation during the follow-up (after implementation of the training program) was 14.5%(265/1832). Upon adjusting for age, the model which best describes the association between follow-up MRSA colonization and health condition of residents includes the following characteristics: Low mobility indicated by Barthel Index 50 or below (adjusted OR = 1.79;1.23,2.60), presence of skin conditions (adjusted OR = 7.72;4.15,14.36), use of medical device (adjusted OR = 2.25;1.55, 3.24) and presence of MRSA at baseline (OR = 5.23;3.81,7.19). Conclusion: We identified a strong association between health conditions of residents and MRSA colonization. MRSA colonization among residents with low mobility suggested that the service setting and environmental contamination may possibly be sources of MRSA transmission. Device care should be a crucial component in the strategic plan, as shown by the association of colonisation with the use of the medical device. Our findings highlighted the importance of the evaluation of intervention strategies for informing infection control policies.

Healthy Diet and Nutrition Education Program among Women of Reproductive Age: A Necessity of Multilevel Strategies or Community Responsibility.

Reproductive years represent a major proportion of women‟s life. This review focuses on recommended nutritional considerations, physical activity pattern as well as the effect of nutrition education (NE) on behavior modification and health outcomes of women of reproductive age using either single-level, multiple-level or community-level interventions. For this narrative review, numerous searches were conducted on databases of PubMed, Science Direct and Google Scholar search engine using the keywords women, reproductive age, NE, interventions, community-based. Even though single intervention is effective, multiple intervention programmes in addition to behavior modification components are even more successful in terms of modified behaviors and health outcomes. Moreover, community based interventions using multilevel strategies are further useful for improved health outcomes and behavior modification. NE programmes have been effective in positive behavior modification measured in terms of eating pattern and health quality. Thus, it is recommended that health professionals use multiple intervention strategies at community level to ensure improved outcomes. Political support is also required to create culturally sensitive methods of delivering nutritional programmes. Finally, as policy is dependent on program cost, nutritional programmes need to combine methods of cost analysis to show cost effectiveness of supplying adequate nutrition for women throughout the lifecycle.

Parent Training and Adolescent Social Functioning: A Brief Report

This brief report describes results from an efficacy test of Adolescent ParentWays program, an intervention developed for parents of adolescents ages 13–16 years who have symptoms of behavioral problems and social difficulties. Families were assigned to one of three groups. The in-person treatment group included parents who attended a 10 week, multiple session intervention program (n = 26), an online only treatment group (n = 29) that was given access to a web-based version of the program, or a wait-listed control group (n = 22). Pre- and post- testing of parents and their adolescent child was conducted. The Adolescent ParentWays intervention program was associated with several significant pre-post differences, including enhanced parent–adolescent relationship quality, increased parent knowledge and monitoring, and lower perceived stress for parents. Significant differences in the outcome variables were found for the in-person treatment group and for the on-line only versions of the program, versus a wait-listed control group. This demonstrates the effectiveness of the Adolescent ParentWays intervention program. The findings support the important role of parents in shaping adolescent behaviors and the positive impact of parenting training programs—both in-person traditional models and well as online versions—in promoting positive parent–adolescent relationships. The merits of using online parent training programs are discussed.

Financial Impact of Foot and Mouth Disease on Large Ruminant Smallholder Farmers in the Greater Mekong Subregion

A retrospective investigation of financial losses incurred by large ruminant smallholder farmers due to outbreaks of foot and mouth disease (FMD) in 2010-12 in northern Laos was conducted in 2012. The aim was to support recommendations on sustainable transboundary animal disease control strategies in the Greater Mekong Subregion (GMS). Large ruminant smallholders in the three northern provinces of Luang Prabang (LPB), Xiengkhoung (XK) and Xayyabouli (XYL) were interviewed (n = 310). Financial losses were determined, including direct losses due to mortality (100% of pre-FMD sale value) and morbidity (difference between the expected sale price pre-FMD and 1 month following onset of FMD), and indirect losses due to costs of treatments. The losses due to FMD per household varied between provinces (P < 0.001) and were USD 1124, USD 862 and USD 381 in LPB, XK and XYL, respectively, being 60, 40 and 16% of annual household income. Comparison of the costs of FMD with annual household income from sales of large ruminants indicated losses of 213, 181 and 60% of the income in LPB, XK and XYL, respectively. The variation in losses between provinces was due to differences in levels of morbidity with highest in LPB, treatment methods with antibiotic use common in LPB, age of animals sold and sale prices with higher prices in XK. Partial budget analysis of biannual FMD vaccination indicated an average net benefit of USD 22 and USD 33 for cattle and buffalo, respectively. However, vaccination alone is unlikely to control FMD in the region. Promotion of multiple large ruminant health and production intervention programmes to stimulate interest in biosecurity in addition to vaccination is recommended, providing a more sustainable pathway for poverty reduction through the current expansion of livestock investments in the GMS.

Barriers, Facilitators, and Recommendations Related to Implementing the Baby-Friendly Initiative (BFI)

Despite growing evidence for the positive impact of the Baby-Friendly Initiative (BFI) on breastfeeding outcomes, few studies have investigated the barriers and facilitators to the implementation of Baby-Friendly practices that can be used to improve uptake of the BFI at the local or country levels. This integrative review aimed to identify and synthesize information on the barriers, facilitators, and recommendations related to the BFI from the international, peer-reviewed literature. Thirteen databases were searched using the keywords Baby Friendly, Baby-Friendly Hospital Initiative, BFI, BFHI, Ten Steps, implementation, adoption, barriers, facilitators, and their combinations. A total of 45 English-language articles from 16 different countries met the inclusion criteria for the review. Data analysis was guided by Cooper's five stages of integrative research review. Using a multiple intervention program framework, findings were categorized into sociopolitical, organizational-level, and individual-level barriers and facilitators to implementing the BFI, as well as intra-, inter-, and extraorganizational recommendations for strengthening BFI implementation. A wide variety of obstacles and potential solutions to BFI implementation were identified. Findings suggest some priority issues to address when pursuing Baby-Friendly designation, including the endorsements of both local administrators and governmental policy makers, effective leadership of the practice change process, health care worker training, the marketing influence of formula companies, and integrating hospital and community health services. Framing the BFI as a complex, multilevel, evidence-based change process and using context-focused research implementation models to guide BFI implementation efforts may help identify effective strategies for promoting wider adoption of the BFI in health services.

Influence of a multiple intervention program for hand hygiene compliance in an ICU

ObjectiveTo assess compliance with hand hygiene (HH) in ICU workers before (P1) and after (P2) implementation of a HH promotion program and distribution of an alcoholic solution for HH, and to analyze factors independently associated to HH before and after patients care. DesignObservational evaluation for 50h of was carried out during each period of the study (P1 and P2); the number of opportunities for HH (before and after patients care) was registered. Educational program (6 months): poster campaign, educational meetings with staff about HH, and the provision of alcohol hand rubs. SettingICU in a secondary level hospital. ParticipantsHealthcare workers in the ICU. InterventionsA quasi-experimental design was used to evaluate compliance with HH before and after implementation of the educational program. VariablesDependent variable: HH compliance before–after patients care; independent variables that might be associated to compliance (including the educational program). ResultsIn P1, there were 338 opportunities for HH both before and after patients care, versus 355 in P2 (before and after patients care). The hand-washing rate was significantly higher in P2 than in P1 (prior to patient care: 45.3% and 34.9%, respectively, and after patient care: 63% and 51.7%, respectively). In the multivariate analysis, the educational program, together with other variables, was significantly associated to HH before and after patients care. ConclusionThere was a significant increase in compliance with hand hygiene among the ICU personnel during the educational phase, both before and after patients care.

Research strategies to improve snakebite treatment: Challenges and progress

Antivenom is an effective treatment of snakebite but, because of the complex interplay of fiscal, epidemiological, therapeutic efficacy and safety issues, the mortality of snakebite remains unacceptably high. Efficiently combating this high level of preventable death amongst the world's most disadvantaged communities requires the globally-coordinated action of multiple intervention programmes. This is the overall objective of the Global Snakebite Initiative. This paper describes the challenges facing the research community to develop snakebite treatments that are more efficacious, safe and affordable than current therapy.

Exploring which context matters in the study of health inequities and their mitigation

This commentary argues that contextual influences on health inequities need to be more thoroughly interrogated in future studies of population health interventions. Case examples were chosen to illustrate several aspects of context: its historical, global, and dynamic nature; its multidimensional character; and its macro- and micro-level influences. These criteria were selected based on findings from an extensive literature review undertaken for the Public Health Agency of Canada and from two invitational symposia on multiple intervention programmes, one with a focus on equity, the other with a focus on context. Contextual influences are pervasive yet specific, and diffuse yet structurally embedded. Historical contexts that have produced inequities have contemporary influences. The global forces of context cross jurisdictional boundaries. A complex set of social actors intersect with socio-political structures to dynamically co-create contextual influences. These contextual influences raise critical challenges for the field of population health intervention research. These challenges must be addressed if we are going to succeed in the calls for action to reduce health inequities. Implications for future public health research and research-funding agencies must be carefully considered.