National Prevention Strategy Research Articles

Long term global evaluation of a national AIDS prevention strategy: the case of Switzerland

The Swiss Aids prevention strategy has been subject to a continuous process of evaluation for the past 12 years. This paper describes the conceptual approach, methodology, results obtained and contribution to policy-making of that evaluation. The evaluation is on-going, global with respect to all components of the strategy, and utilization-focused. Each successive phase of the evaluation has included 10-20 studies centred either on aspects of process, of outcome or of environmental context. Findings are synthesized at the end of each phase. Both quantitative and qualitative methods are used. Studies generally have one of three functions within the overall evaluation: assessment of trends through surveys or other types of repeated studies; evaluation of specific areas through a series of studies from different viewpoints; in-depth investigation or rapid assessment through one-off studies. Various methods of triangulation are used to validate findings. The evaluation has allowed for: the observation of behavioural change in different populations; the availability of scientific data in controversial fields such as drug-use policy; an understanding of the diversity of public appropriation of prevention messages. Recommendations are regularly formulated and have been used by policy-makers and field workers for strategy development. The global approach adopted corresponds well to the evaluation requirements of an integrated long-term prevention strategy. Cost is low relative to the extent of information provided. Such an evaluation cannot however address the question of causal relationship between the strategy and observed changes. The evaluation has contributed to the development of a culture of evaluation in Swiss AIDS prevention more generally.

Prevention of HIV infection through changes in sexual behavior.

Ample evidence exists that behavioral interventions reduce high risk sexual behaviors and promote safer practices. Downstream interventions in settings attracting high risk patients work well, especially with infected persons to avert new infections. Preparing health care workers for intensive, skills-based interventions grounded in behavioral science theory would enhance primary prevention. Midstream interventions have reliably reduced risk in primary care and community settings. Adoption of comprehensive skills-based programs in schools is controversial but likely to improve outcomes. Upstream community approaches have slowed human immunodeficiency virus (HIV) incidence among men having sex with men. Upstream policy interventions remain underutilized in the U.S. but have been successful internationally. Needed are a national HIV prevention strategy and research linking behavior change to reduced HIV seroprevalence.

O51. Forensic nursing: a national crime prevention strategy in South Africa

O51. Forensic nursing: a national crime prevention strategy in South Africa

Childhood Epidemiology of Hepatitis a Virus in Riyadh, Saudi Arabia

The prevalence of anti-HAV antibody in children was tested in subjects presenting at clinics in Riyadh, Saudi Arabia. A blood sample was taken to test for the presence of IgG (indicating past infection) and a questionnaire concerning personal and epidemiological data relating to hepatitis A was completed. In total, 592 children aged 6 months to 15 years were suitable for the analysis. There were 179 subjects who were positive for HAV (30.2%). The proportions of subjects positive for HAV varied significantly with age (P=0.001); 32%-49% in the 7-15 age range were positive compared with 13-20% aged 6 and below. There was a significant association between a positive HAV test and social level (P=0.044), with a higher proportion positive in the low social level. Children with jaundice, personal history of jaundice or travel abroad were significantly more likely to be HAV positive (P=0.001, P=0.006, P=0.021, respectively). There was also a significant association with nationality (P=0.022), where the lowest proportion of HAV positive children were Saudi Arabian (28%). Compared to previous studies, there is a significant decrease in the HAV exposure in Saudi children with shift from high to intermediate pattern. National strategy for prevention should be evaluated.

Injecting nation: achieving control of hepatitis C in Australia

Since Australia banned heroin in 1953 consumption of illicit drugs, deaths, crime and corruption related to drugs have steadily increased. Injecting drug use (IDU) in Australia is now a significant public health problem linked each year to approximately 500 overdose deaths and more than 6000 hepatitis C infections. At least 85% of prevalent and incident hepatitis C cases in Australia are injecting drug users (IDUs) with annual incidence estimated at 15%. Although poorly documented, increasing numbers of patients with end-stage liver disease from hepatitis C now appear to present in Australia. This reflects a heroin-injecting epidemic commencing a quarter of a century ago, the close association between drug injecting and hepatitis C and the long delay between hepatitis C infection and complications. The overall health and economic burden of hepatitis C may soon exceed HIV. Control is far more difficult to achieve for hepatitis C than HIV because of much higher baseline prevalence levels and far greater infectiousness by blood to blood spread. Transmission appears to follow minimal breaches of infection control guidelines. Hepatitis C has not yet become a priority public health issue in Australia. No national prevention strategy has been proposed. Prevention strategies (such as needle exchange or methadone) which controlled HIV among IDUs should be expanded, with the expectation of some useful reduction of spread but without achieving control of hepatitis C. Other options for control must be considered. Eradicating illicit drug use in Australia is unachievable. Virtually eradicating injecting drug use by facilitating a switch to non-injecting routes of administration (NIROA) is achievable (although difficult) and this could control hepatitis C. NIROA will have the probable additional benefit of reducing drug overdose deaths. NIROA has begun recently to replace injecting in several countries without government intervention. Powerful cultural, pharmacological and economic factors strongly reinforce drug injecting. Economic impediments to NIROA could be reduced by drug policy reform. Facilitating a switch to NIROA carries some risk of increased discrimination directed against an already marginalized population. A major obstacle to harm reduction is the common assumption that any relaxation of drug policy invariably leads to increased consumption. Switching the predominant route of administration of illicit drugs from IDU to NIROA should be the major focus of national efforts to control hepatitis C and overdose deaths in Australia.

AIDS information needs: conceptual and content analyses of questions asked of AIDS information hotlines.

Dissemination of accurate information about HIV is an essential element of national AIDS prevention strategies and AIDS telephone hotlines serve a vital function in providing such information. In this study, questions asked of two AIDS information hotlines were collected and examined to determine the AIDS information needs of the general public. Questions asked of local AIDS lines in Houston and Milwaukee (N = 1611) were independently classified into 30 content areas, with two independent raters achieving 94% agreement. The content areas were organized for analysis into 11 broader information domains. Questions about HIV antibody testing were the most frequently asked (27%), followed by questions about sexual transmission of HIV (16%), HIV-related symptoms (16%) and situations that do not confer risk for HIV infection (14%). Content analyses suggested that individuals were motivated to call hotlines by fears of contracting HIV from actual risk behaviors or to dismiss concerns about contracting HIV through casual modes. Many individuals had information needs related to their own personal experiences that could not be addressed through media campaigns or other means of mass public health education. Results suggest that HIV information dissemination to the public through hotlines and other means of direct health education serves both preventive and destigmatizing functions.

Using existing health care systems to respond to the AIDS epidemic: research and recommendations for Chile.

Chile is a country with a relatively low prevalence of HIV infection, where successful prevention has the potential to change the future course of the epidemic. A controversial national prevention strategy based upon public education has emerged in response to characterizations of the epidemic as well-dispersed with a growing involvement of heterosexuals. This characterization is not consistent with the observed facts. There is a comparatively well-organized health care system in Santiago that is doing a good job of detecting HIV infection and already has in place the elements of a targeted intervention scheme. Chile should place priority on the use of the existing health care infrastructure for implementing both the traditional public health interventions for sexually transmitted diseases (contact tracing and partner notification) and the AIDS-necessitated strategy of focused counseling and education.

Epidemiology and implications of ocular trauma admitted to hospital in Scotland.

To describe the current epidemiology of serious ocular trauma which necessitates admission to hospital so that health and safety strategies for the prevention of ocular injuries and their role within the national health strategy, The Health of the Nation, can be better informed. A prospective observational study of all patients with ocular trauma admitted to hospital under the care of a consultant ophthalmologist between 1 November 1991 and 31 October 1992. All ophthalmic department in Scotland. All patients with ocular trauma admitted to hospital in Scotland. The population of Scotland represented the population at risk of injury. Measures included the type and cause of injury, the place where it occurred, and awareness of risk and safety. All ophthalmic departments in Scotland participated and 428 admissions were reported. The home was the most common place for a serious injury to occur (30.2%), followed by the workplace (19.6%) and a sports or leisure facility (15.8%). The home was the single most frequent place of injury for the 0-15 year and 65 year and over age groups. Tools or machinery, either at home (13.9%) or at work (10.3%), were collectively (24.2%) the most frequent cause of injury, followed by assault (21.8%) and sports-related activities (12.5%). The most frequent type of injury was a blunt injury (54.4%). Six per cent (n = 25) of all injuries were bilateral. Only 13.2% of patients were aware of any risk of injury, with 5.6% aware of any risk at home. When applicable, protective eye wear was only available to 48.6% of patients and only 19.4% of these used it. Serious ocular trauma frequently occurs at home and the young and the elderly are particularly at risk. This represents a significant change in the epidemiology of serious ocular trauma and has important implications for prevention. Health and safety strategies specifically aimed at preventing eye injury should now include the home as a high risk environment in addition to the work-place and sports/leisure facilities. The target groups for accident prevention in The Health of the Nation strategy include those at risk of serious ocular trauma with potentially sight threatening sequelae. Those involved in implementing the national accident prevention strategy should be aware of this, for in this process it is possible that some serious eye injuries may also be prevented.

Seroepidemiology of HBV and HCV in India. Strategy for control of maternal transmission of HBV and its effect. Screening methods of blood donors for control of post-transfusion hepatitis and their effects

The HBV prevalence rate in India is 2–8 percent with an approximate carrier pool of 36 million. India being a large country, the HBV carrier and infection rate varies in different regions of the country. HBV prevalence is highest in South India (5.5%). The high risk population for HBV carrier state as well as for HBV infection includes professional blood donors (10–11%), patients undergoing hoemodialysis (65.8%), residential population of orphanage (15.3%), and parenteral drug abusers (8.5%). Medical and paramedical personnel dealing with dental surgery, and truck drivers in North India also carry a higher HBV prevalence. Vertical or perinatal transmission of HBV in India, unlike in South-East Asia, is infrequent due to a low HBeAg positivety rate (7.8%) among pregnant females with HBV infection. On the other hand, horizontal transmission in early childhood due to crowded and unhygienic living conditions is the major role of spread for HBV infection in India. Amongst adults, transfusion of blood collected from professional blood donors constitutes another important mode of HBV transmission. HBV is an important cause of liver disease in India and is responsible for 42% of acute hepatitis, 33% of acute liver failure, 34% of subacute liver failure, 68% of chronic hepatitis, 80% of cirrhosis and 61% of Hepatocellular carcinoma. HCV related liver disease is infrequent and anti HCV antibody positivity rates are low in the general population (0.9%). HCV antibody positivity in patients with chronic liver disease is approximately 13%. At present there is no national strategy for HBV prevention in India and motivated clinicians are making individual efforts to promote HBV immunization. Post transfusion hepatitis related to professional blood use continues to be an important cause of HBV and HCV related liver disease in India. Screening of blood for HBsAg and anti HCV antibody needs to be widely practised to control the frequency of transfusion related liver disease in India.

Hepatitis C virus infection and chronic liver disease in Ethiopia where hepatitis B infection is hyperendemic

To assess the prevalence and possible aetiological association of hepatitis C virus (HCV) with chronic liver disease and hepatocellular carcinoma (HCC), antibodies to HCV (anti-HCV) were determined by enzymelinked immunosorbent and recombinant immunoblot assays in 500 healthy volunteer blood donors, 14 patients with chronic hepatitis, 156 cirrhotics and 68 cases of hepatocellular carcinoma (HCC) in Ethiopia. The prevalences of anti-HCV were 1·4%, 21%, 36% and 46%, respectively. There was no apparent risk factor to suggest the mode of transmission of HCV. Of the 238 patients, 65 (27%) had circulating hepatitis B surface antigen (HBsAg) (denoting current infection), 131 (55%) had antibodies to hepatitis B surface (anti-HBs) and/or core (anti-HBc) antigens (past infection) and 42 (18%) had no hepatitis B virus (HBV) marker. Anti-HCV antibodies were present in only one patient with HBsAg, in 54% with past infection and in 68% of those without HBV markers. Thus, HCV infection was uncommon in HBsAg-positive patients but significantly more common in patients with chronic liver disease and HCC who had evidence of past HBV infection or no marker for HBV infection. HCV infection appeared to be a more common cause of chronic liver disease and HCC than HBV infection in this population. However, considering the high prevalence of overall exposure to HBV infection (68% in healthy blood donors and 82% in those with chronic liver disease, including HCC), HBV is significant in terms of national preventive strategies.

US health care reform and the economy of prevention.

The current dialogue on reform of the US health care system is conspicuous for the absence of an epidemiologically driven framework that focuses on the prevention of disease. Review of epidemiologic and demographic trends in the American population illustrates that if reform fails to advance the point of intervention to earlier in the course of disease, a restructured health care system is unlikely to provide comprehensive services with universal access. Sustainable reform warrants a preventive orientation and greater balance between primary, secondary, and tertiary levels of intervention. This report considers trends that may render economically driven reform rapidly obsolete, as well as cultural obstacles to the development of a prevention ethos in US health care and culture. The economy of prevention is described in the context of leading causes of US morbidity and mortality. Elements of a national disease prevention strategy are considered that include changes in mechanisms of physician/provider reimbursement, the orientation of private-sector biotechnology/health care research, tertiary medical centers and academia, and improved abilities to reduce the concentration of preventable morbidity and mortality in high-risk communities and to use epidemiology in formulating health policy.

Mandatory Testing for HIV

To the Editor. —Dr Francis' 1 no-nonsense proposal for a CDC-led national HIV prevention program is like a sniff of smelling salts after a deep swoon. JAMA readers of all political persuasions should examine it carefully. Reading it, I recalled an October 1981 conversation with Francis. As the KS-OI (Kaposi's sarcoma-opportunistic infection) (AIDS) Coordinator for the CDC's Center for Infectious Diseases, I had been developing a CDC plan to search for an infectious causative agent that I imagined might be epidemiologically similar to sexually transmitted cytomegalovirus. Francis suggested a better idea: perhaps the then poorly understood outbreak of Kaposi's sarcoma and opportunistic infections was due to a sexually transmitted retrovirus. This was the first time, to my knowledge, that anyone correctly theorized the cause of the AIDS epidemic. Later discoveries, of course, showed how prescient Francis had been. Are his ideas for a national HIV prevention strategy equally farsighted? He

Evolution of the national disease prevention and health promotion strategy: establishing a role for the schools.

The history and evolution, during the past decade, of the national disease prevention and health promotion strategy is recounted, culminating with a description of the national prevention objectives. Objectives that directly could be attained by: (1) school health education; (2) school health services; (3) efforts to ensure healthy school environments; and (4) school physical education programs are delineated, as are objectives that could be influenced in important ways by school health programs. The nation's schools could contribute significantly and measurably toward improving the health of all Americans, if school health professionals, individually as well as within their various organizations, could seize and create opportunities to work with other health and educational professionals, and the public, to impel and enable schools to attain relevant national prevention objectives.

A national strategy for prevention. A general dental practitioner's personal view.

A national strategy for prevention. A general dental practitioner's personal view.