C-reactive protein is a sensitive but nonspecific systemic marker of inflammation. Several prospective studies have investigated the association of prediagnostic circulating C-reactive protein concentrations with the development of colorectal cancer, but the results have been inconsistent. We performed a systematic review of prospective studies of the association between prediagnostic measurements of circulating high-sensitivity C-reactive protein and development of invasive colorectal cancer. Authors of original studies were contacted to acquire uniform data. We combined relative risks (RR) for colorectal cancer associated with a one unit change in natural logarithm-transformed high-sensitivity C-reactive protein using inverse variance weighted random effects models. We identified eight eligible studies, which included 1,159 colorectal cancer cases and 37,986 controls. The summary RR per one unit change in natural log-transformed high-sensitivity C-reactive protein was 1.12 (95% confidence intervals [CI], 1.01-1.25) for colorectal cancer, 1.13 (95% CI, 1.00-1.27) for colon cancer, and 1.06 (95% CI, 0.86-1.30) for rectal cancer. The association was stronger in men (RR, 1.18; 95% CI, 1.04-1.34) compared to women (RR, 1.09; 95% CI, 0.93-1.27) but this difference was sensitive to the findings from a single study. Prediagnostic high-sensitivity Creactive protein concentrations were weakly associated with an increased risk for colorectal cancer. More work is needed to understand the extent to which circulating high-sensitivity C-reactive protein or other blood inflammatory markers are related to colonic inflammation. ' 2008 Wiley-Liss, Inc.Key words: meta-analysis; C-reactive protein; inflammation; colorectal neoplasms C-reactive protein (CRP) is a sensitive but nonspecific systemic marker of inflammation.1 CRP is produced mainly in the liver along with other acute-phase proteins in response to cytokines released by phagocytes during infection, trauma, surgery, burns, tissue infarction, advanced cancer and chronic inflammatory conditions.2-4 Several lines of evidence suggest that colorectal neoplasia may arise from colonic areas with chronic subclinical inflammation. 5 Investigators have hypothesized that CRP may act as a biomarker for chronic low-grade intestinal inflammation and the subsequent development of colorectal cancer.Several retrospective case-control studies have compared CRP concentrations between colorectal cancer patients and healthy controls, and have reported at least 10-fold higher concentrations in the cancer patients.6-9 These findings may be explained to some extent by reverse causality due to the host inflammatory response to existing advanced cancer among cases. Prospective studies, where CRP is measured long before cancer diagnosis in all participants, are thus required to answer whether CRP is associated with colorectal cancer incidence. Findings from such studies, however, have been inconsistent. The reasons underlying these heterogeneous findings need to be investigated, but no formal meta...

BackgroundThe premise of patient-centered care is to empower patients to become active participants in their own care and receive health services focused on their individual needs and preferences. Afghanistan has evidenced enormous gains in coverage and utilization, but the quality of care remains suboptimal, as evidenced in the balanced scorecard (BSC) performance assessments. In the United States and throughout Africa and Asia, community scorecards (CSC) have proved effective in improving accountability and responsiveness of services. This study represents the first attempt to assess CSC feasibility in a fragile context (Afghanistan) through joint engagement of service providers and community members in the design of patient-centered services with the objective of assessing impact on service delivery and perceived quality of care.MethodsSix primary healthcare facilities were randomly selected in three provinces (Bamyan, Takhar and Nangarhar) and communities in their catchment area were selected for the study. Employing a multi-stakeholder strategy, community members and leaders, health councils, facility providers, NGO managers, and provincial directorates were engaged in a five-phase process to jointly identify structural and service delivery indicators (about 20), score performance and subsequently develop action plans for instituting improvements through participatory research methods. Three rounds of CSC assessments were conducted in each community. Over 470 community members, 34 health providers, and other provincial ministry staff participated in the performance audits.ResultsStructural capacity indicators including the number and cadre of service providers, particularly female providers, water and power supply, waiting rooms, essential medicines, and equipment scored low in the first round (30–50 %). Provider courtesy and quality of care received high scores (>90 %) throughout the study. Unrealistic community demands for ambulances and specialist doctors were mitigated by community education of entitlements described in the national standards for essential package of services. The joint interface meeting facilitated transparent dialogue between the community and providers and resulted in creative and participatory problem solving mechanisms and mobilization of resources.ConclusionThese results indicate the potential of the CSC as a tool for enhancing social accountability for patient-centered care. However, the process requires skilled facilitators to effectively engage communities and healthcare providers and adaptation to specific healthcare contexts.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-0946-5) contains supplementary material, which is available to authorized users.

Twenty years after the rights of women to go through pregnancy and childbirth safely were recognized by governments, we assessed the effects of interventions that promote awareness of these rights to increase use of maternity care services. Using inclusion and exclusion criteria defined in a peer-reviewed protocol, we searched published and grey literature from one database of studies on maternal health, two search engines, an internet search and contact with experts. From the 707 unique documents found, 219 made reference to rights, with 22 detailing interventions promoting awareness of rights for maternal and newborn health. Only four of these evaluated effects on health outcomes. While all four interventions promoted awareness of rights, they did so in different ways. Interventions included highly-scripted dissemination meetings with educational materials and other visual aids, participatory approaches that combined raising awareness of rights with improving accountability of services, and broader multi-stakeholder efforts to improve maternal health. Study quality ranged from weak to strong. Measured health outcomes included increased antenatal care and facility birth. Improvements in human rights outcomes such as availability, acceptability, accessibility, quality of care, as well as the capacity of rights holders and duty bearers were also reported to varying extents. Very little information on costs and almost no information on harms or risks were described. Despite searching multiple sources of information, while some studies did report on activities to raise awareness of rights, few detailed how they did so and very few measured effects on health outcomes. Promoting awareness of rights is one element of increasing demand for and use of quality maternity care services for women during pregnancy, birth and after birth. To date efforts have not been well documented in the literature and the program theories, processes and costs, let alone health effects have not been well evaluated.

BackgroundPromoting awareness of rights is a value-based process that entails a different way of thinking and acting, which is at times misunderstood or deemed as aspirational.MethodsGuided by the SURE framework, we undertook a secondary analysis of 26 documents identified by an earlier systematic review on promoting awareness of rights to increase use of maternity care services. We thematically analysed stakeholder experiences and implementation factors across the diverse initiatives to derive common elements to guide future efforts.ResultsInterventions that promote awareness of rights for maternal health varied in nature, methodological orientation, depth and quality. Materials included booklets, posters, pamphlets/ briefs and service standards/charters. Target populations included women, family members, communities, community structures, community-based and non governmental organizations, health providers and administrators, as well as elected representatives. While one initiative only focused on raising awareness, most were embedded within larger efforts to improve the accountability and responsiveness of service delivery through community monitoring and advocacy, with a few aiming to change policies and contest elections. Underlying these action oriented forms of promoting awareness of rights, was a critical consciousness and attitudinal change gained through iterative capacity-building for all stakeholders; materials and processes that supported group discussion and interaction; the formation or strengthening of community groups; situational analysis to ensure adaptation to local context; facilitation to ensure common ground and language across stakeholders; and strategic networking and alliance building across health system levels. While many positive experiences are discussed, few challenges or barriers to implementation are documented. The limited documentation and poor quality of information found indicate that while various examples of promoting awareness of rights for maternal health exists, research partnerships to systematically evaluate their processes, learning and effects are lacking.ConclusionRather than being aspirational, several examples of promoting awareness of women’s rights for quality maternity care services exist. More than mainly disseminate information, they aim to change stakeholder mindsets and relationships across health system levels. Due to their transformatory intent they require sustained investment, with strategic planning, concrete operationalization and political adeptness to manage dynamic stakeholder expectations and reactions overtime. More investment is also required in research partnerships that support such initiatives and better elucidate their context specific variations.

Global efforts to scale-up the community health workforce have accelerated as a result of the growing evidence of their effectiveness to enhance coverage and health outcomes. Reconstruction efforts in Afghanistan integrated capacity investments for community based service delivery, including the deployment of over 28,000 community health workers (CHWs) to ensure access to basic preventive and curative services. The study aimed to conduct capacity assessments of the CHW system and determine stakeholder perspectives of CHW performance. Structured interviews were conducted on a national sample from 33 provinces and included supervisors, facility providers, patients, and CHWs. Formative assessments were also conducted with national policymakers, community members and health councils in two provinces. Results indicate that more than 70% of the NGO's provide comprehensive training for CHWs, 95% CHWs reported regular supervision, and more than 60% of the health posts had adequate infrastructure and essential commodities. Innovative strategies of paired male and female CHWs, institution of a special cadre of community health supervisors, and community health councils were introduced as systems strengthening mechanisms. Reported barriers included unrealistic and expanding task expectations (14%), unsatisfactory compensation mechanisms (75%), inadequate transport (69%), and lack of commodities (40%). Formative assessments evidenced that CHWs were highly valued as they provided equitable, accessible and affordable 24-h care. Their loyalty, dedication and the ability for women to access care without male family escorts was appreciated by communities. With rising concerns of workforce deficits, insecurity and budget constraints, the health system must enhance the capacity of these frontline workers to improve the continuum of care. The study provides critical insight into the strengths and constraints of Afghanistan's CHW system, warranting further efforts to contextualize service delivery and mechanisms for their support and motivation.