This paper presents the first published report of a national-level effort to implement the Integrated Management of Childhood Illness (IMCI) strategy at scale. IMCI was introduced in Peru in late 1996, the early implementation phase started in 1997, with the expansion phase starting in 1998. Here we report on a retrospective evaluation designed to describe and analyze the process of taking IMCI to scale in Peru, conducted as one of five studies within the Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (MCE) coordinated by the World Health Organization. Trained surveyors visited each of Peru's 34 districts, interviewed district health staff and reviewed district records. Findings show that IMCI was not institutionalized in Peru: it was implemented parallel to existing programmes to address acute respiratory infections and diarrhoea, sharing budget lines and management staff. The number of health workers trained in IMCI case management increased until 1999 and then decreased in 2000 and 2001, with overall coverage levels among doctors and nurses calculated to be 10.3%. Efforts to implement the community component of IMCI began with the training of community health workers in 2000, but expected synergies between health facility and community interventions were not realized because districts where clinical training was most intense were not those where community IMCI training was strongest. We summarize the constraints to scaling up IMCI, and examine both the methodological and policy implications of the findings. Few monitoring data were available to document IMCI implementation in Peru, limiting the potential of retrospective evaluations to contribute to programme improvement. Even basic indicators recommended for national monitoring could not be calculated at either district or national levels. The findings document weaknesses in the policy and programme supports for IMCI that would cripple any intervention delivered through the health service delivery system. The Ministry of Health in Peru is now working to address these weaknesses; other countries working to achieve high and equitable coverage with essential child survival interventions can learn from their experience.

The Multi-Country Evaluation of Integrated Management of Childhood Illness (IMCI) Effectiveness, Cost and Impact (MCE) was launched to assess the global effectiveness of this strategy. Impact evaluations were started in five countries. The objectives of the Peru MCE were: (1) to document trends in IMCI implementation in the 24 departments of Peru from 1996 to 2000; (2) to document trends in indicators of health services coverage and impact (mortality and nutritional status) for the same period; (3) to correlate changes in these two sets of indicators, and (4) to attempt to rule out contextual factors that may affect the observed trends and correlations. An ecological analysis was performed in which the units of study were the 24 departments. By 2000, 10.2% of clinical health workers were trained in IMCI, but some districts showed considerably higher rates. There were no significant associations between clinical IMCI training coverage and indicators of outpatient utilization, vaccine coverage, mortality or malnutrition. The lack of association persisted after adjustment for several contextual factors including socioeconomic and environmental indicators and the presence of other child health projects. Community health workers were also trained in IMCI, and training coverage was not associated with any of the process or impact indicators, except for a significant positive correlation with mean height for age. According to the MCE impact model, IMCI implementation must be sufficiently strong to lead to an impact on health and nutrition. Health systems support for IMCI implementation in Peru was far from adequate. This finding, along with low training coverage level and a relatively low child mortality rate, may explain why the expected impact was not documented. Nevertheless, even districts with high levels of training coverage failed to show an impact. Further national effectiveness studies of IMCI and other child interventions are warranted as these interventions are scaled up.

This article reviews the implementation of the community component of the Integrated Management of Childhood Illness (IMCI) strategy in Chao, Peru (2001 to 2004) and San Luis, Honduras (2003 to 2005). An evaluation was conducted in 2005 and included a project documentation review, key-informant interviews, and a household level baseline and follow-up survey of the WHO/UNICEF key family practices in each intervention site. The promotion of the key family practices in Chao and San Luís demonstrated measurable success. In comparison with the initial survey in 2002, the percentage of participant mothers ( N = 78) in Chao in 2004 who knew that they should breastfeed exclusively for at least six months increased from 33% to 94%; the presentation of complete vaccination records for one-year-old children increased by 19%; the recognition of danger signs for pneumonia increased 18% and for diarrhea by 8%; and the percentage of mothers who received four or more prenatal check-ups increased by 25%. A dramatic reduction in malaria cases was also attributed to the intervention in Chao. In San Luis, a quasi-experimental, random household sample ( N = 300) showed that the incidence of diarrheal disease among children under five years old declined by 18% between survey rounds (from 44% in August 2004 to 26% in December 2005). Social mobilization has promoted inter-sector consensus-building around community health issues, especially those related to maternal and child health. The promotion of the participation of representatives from various organizations via the community IMCI social-actor methodology has led to increased civic cooperation. Positive changes in health behaviors have been documented through an increase in preventive health practices, greater demand for primary health care services, and concrete community actions to improve public health.

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En este informe se presentan las diversas definiciones de casos de cólera usadas en los países de América Latina que se han visto afectados por la epidemia; se da el número de casos de cólera y de las defunciones por la enfermedad (según datos notificados a la OPS por los países latinoamericanos en 1993), y se describen algunas tendencias regionales de la incidencia de cólera. La información relacionada con la forma en que se definieron los casos de la enfermedad se obtuvo por medio de un cuestionario administrado por la OPS en octubre de 1993. En total, 948 429 casos de cólera fueron notificados a la OPS entre enero de 1991 y diciembre de 1993 por los países latinoamericanos afectados por la epidemia y las incidencias anuales más altas se registraron en el Perú (1991 y 1992) y Guatemala (1993). La tasa de letalidad para todo el trienio, y también para 1993, fue de 0,8%. La incidencia de cólera mostró una tendencia descendente general en la mayor parte de los países sudamericanos pero aumentó en casi todos los países de Centroamérica. Se observó gran variabilidad en las definiciones aplicadas para notificar casos de cólera, casos de cólera hospitalizados y defunciones atribuibles al cólera. Esta variabilidad dificulta cualquier comparación global entre países (y hasta estimar la carga de morbilidad y evaluar la calidad de la atención sobre la base de las tasas de letalidad), y aun las tendencias notificadas dentro de un mismo país deben evaluarse con cuidado. Es muy probable que en un futuro la situación se complique por la llegada de la cepa Vibrio cholerae 0139 a América Latina, situación que genera la necesidad de distinguir entre ella y la cepa 01, que es la predominante. Para efectos de simplificación y para lograr la amplia aceptación y extensa divulgación de la información sobre los casos, se recomiendan las siguientes definiciones: caso confirmado de cólera 01: infección por V. cholerae 01 toxígeno, confirmada por métodos de laboratorio, en cualquier persona con diarrea. Caso confirmado de cólera 0139: infección confirmada por V. cholerae 0139 toxígeno, confirmada por un laboratorio, en cualquier persona con diarrea. Caso clínico de cólera: diarrea acuosa de carácter agudo en una persona mayor de 5 años que busca tratamiento. Defunción atribuible al cólera: defunción durante la semana inmediatamente posterior al comienzo de la diarrea en una persona con cólera confirmado o diagnosticado según la definición clínica. Paciente hospitalizado con cólera: persona con cólera confirmado o diagnosticado según la definición clínica que pasa un mínimo de 12 horas en un centro de atención para el tratamiento de la enfermedad.

This study explores the effects of social integration on behavioral change in the course of an intensive, community-based public health intervention. The intervention trained volunteers and mobilized local organizations to promote 16 key family health practices in rural San Luis, Honduras, during 2004 to 2006. A mixed methods approach is used. Standard household sample surveys were performed in 22 villages before and after the intervention. Eight villages were then resurveyed. A household survey, focus groups, and key informant interviews measured health behaviors and several social structural and psychosocial variables. The villages were then ranked on their mean behavioral and social integration scores. The quantitative and qualitative rankings were in close agreement (Kendall's coefficient of concordance = .707, p < .001). Behaviors changed most markedly in the villages where respondents participated in local organizations, observed that others performed those behaviors, and depended on their neighbors for support. The results show that social integration conditions health behavioral change. Health interventions can be made more effective by analyzing these features a priori.

and the ease of work with the medication administration process after implementation of a bedside bar-coded medication administration system and a medication dispensing system in an intensive care unit (ICU) at a tertiary hospital. METHODS: A prospective cohort study was conducted to compare medication administration time before and after these two interventions using a pre-validated instrument. The bedside bar-coded medication administration system was implemented in 2008 and the medication dispensing system was implemented in 2009. Perception of nurses regarding timeliness of completion, documentation burden, administration burden, and ease of detection of medication errors during the medication administration process were measured using a 5 point Likert scale -from 1 (Strongly Disagree) to 5 (Strongly Agree). Descriptive and comparative (t test) analyses were conducted using SAS 9.2® to evaluate the impact of technological intervention on the nurses' perception. RESULTS: A total of 99 pre-intervention and 109 post-intervention responses were recorded for every medication administration process. Mean (Ϯ SD) perception score regarding timeliness of completion has been significantly (pϽ0.05) reduced from the pre-intervention period (2.8 Ϯ2.1) to the post intervention period (1.6Ϯ2.2). Similarly, mean scores for documentation (pre: 3.2Ϯ1.9 vs. post: 1.6Ϯ2.2) and administration (pre: 2.8Ϯ2.2 vs. post: 1.6Ϯ2.2) burden also improved significantly (pϽ0.05) after the intervention. There was no significant change in the perception score regarding ease of detection of medication errors (pre: 2.3Ϯ2.3 vs. post: 1.7Ϯ2.3). CONCLUSIONS: Nurses perceived less documentation and administration burden after the implementation of the technological intervention. These opinions help validate the role of health technology assessment in improving performance. OBJECTIVES:To evaluate the current national trends in Vitamin D prescribing among the elderly seeking care in office-based physician provider settings. METHODS: Cross-sectional study was conducted using the National Ambulatory Medical Care Survey (NAMCS) data from 2000 to 2009. All ambulatory office visits made by the elderly aged Ն65 years of age were included in the study. Bivariate associations between vitamin D and study variables such as patient demographics, region, physician's specialty, insurance status, and osteoporosis diagnosis were evaluated using chi square tests. Logistic regression analyses were conducted to determine the predictive factors associated with a vitamin D. All analyses were performed with SAS statistical software, version 9.1, at an alpha of 0.05. RESULTS: Of the 279,819 office-based physician visits made by the NAMCS participants from 2000 through 2009, there were 74,904(26.7%) visits that met the inclusion criteria. This estimate represented 2.4 billion physician-office visits from the elderly in the United States during the 10-year period. Of the included visits, 1,112 (1.91%) were associated with a vitamin D. Race was a significant predictor in bot...

ResumenEste artículo presenta el primer reporte publicado de un esfuerzo nacional de implementación de la atención integrada a las enfermedades prevalentes de la infancia (Aiepi)