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Problem Maternal and neonatal mortality remains high in low- and middle-income countries, with poor quality of intrapartum care as a barrier to further progress. Approach We developed and tested a method of measuring the quality of maternal and neonatal care that could be embedded in a larger national performance management initiative. The tool used direct observations and medical record reviews to score quality in nine domains of intra partum care. We piloted and evaluated the tool in visits to the 18 lead hospitals that have responsibility to promote and coordinate quality improvement efforts within a hospital cluster in Ethiopia. Between baseline and follow-up assessments, staff from a national quality collaborative alliance provided hospital-based training on labour and delivery services. Local setting Ethiopia has invested in hospital quality improvement for more than a decade and this tool was integrated into existing quality improvement mechanisms within lead hospitals, with the potential for scale-up to all government hospitals. Relevant changes Significant improvements in quality of intrapartum care were detected from baseline (June-July 2015) to follow-up (February-March 2016) in targeted hospitals. The overall mean quality score rose from 65.6 (standard deviation, SD: 10.5) to 91.2 (SD: 12.4) out of 110 items (P < 0.001). Lessons learnt The method was feasible, requiring a total of 3 days and two to three trained data collectors per hospital visit. It produced data that detected substantial changes made during 8 months of national hospital quality improvement efforts. With additional replication studies, this tool may be useful in other low- and middle-income countries. Qualite de ses hopitaux depuis plus de dix ans, et cet outil a ete integre aux mecanismes existants d'amelioration de la qualite de ces hopitaux principaux, avec la perspective de l'etendre eventuellement a tous les hopitaux gouvernementaux. Changements significatifs Des ameliorations considerables de la qualite des soins intrapartum ont ete constatees entre les donnees initiales (juin a juillet 2015) et les donnees de suivi (fevrier a mars 2016) dans les hopitaux cibles. Le score global moyen de la qualite est passe de 65,6 (ecart type, ET: 10,5) a 91,2 (ET: 12,4) pour les 110 elements evalues (P < 0,05). Lecons tirees La methode etait realisable, necessitant pour chaque visite troisjours et entre deux ettrois collecteurs de donnees experimentes. Elle a permis d'obtenir des donnees refletant les changements importants survenus en huit mois d'efforts d'amelioration de la qualite des hopitaux nationaux. Moyennant des etudes de reiteration complementaires, cet outil pourrait etre utile dans d'autres regions a revenu faible et intermediaire. Probleme La mortalite maternelle et la mortalite neonatale restent elevees dans les pays a revenu faible et intermediaire, oU la qualite insuffisante des soins pratiques pendant l'accouchement constitue un frein a la progression dans ce domaine. Approche Nous avons concu et teste une methode pour evaluer la qualite des soins dispenses aux meres et aux nouveau-nes, qui pourrait etre integree a une initiative nationale de gestion des performances de plus grande envergure. Grace a des observations directes et a l'examen des registres medicaux, notre outil a permis d'attribuer un score de qualite dans neuf domaines de soins intrapartum. Nous avons applique et teste notre outil dans le cadre de la visite des 18 hopitaux principaux ayant chacun la responsabilite de promouvoir et de coordonner les efforts d'amelioration de la qualite au sein d'un groupement d'hopitaux en Ethiopie. Entre les evaluations de depart et les evaluations ulterieures de suivi, le personnel d'une alliance nationale de collaboration pour la qualite a dispense des formations dans les hopitaux sur les services realises pendant le travail et l'accouchement. Environnement local L'Ethiopie investit dans l'amelioration de la integrado a los mecanismos existentes de mejora de la calidad en los hospitales mas importantes, con potencial para llegar a todos los hospitales publicos. Cambios importantes Se detectaron mejoras significativas en la calidad de la atencion durante el parto desde el principio (junio-julio de 2015) hasta el seguimiento (febrero-marzo de 2016) en los hospitales estudiados. La calidad media general obtuvo una puntuacion de 65,6 (desviacion estandar, DE: 10,5) a 91,2 (DE: 12,4) de 110 elementos (P < 0,05). Lecciones aprendidas El metodo fue viable, necesitando un total de tres dias y de dos a tres recopiladores de datos con formacion por visita hospitalaria. Se generaron datos que detectaron grandes cambios durante los ocho meses de trabajos de mejora de la calidad de los hospitales. Con otros estudios de reproduccion, esta herramienta podria resultar util en otros paises con ingresos bajos y medios. Situacion La mortalidad materna y neonatal sigue siendo alta en paises con ingresos bajos y medios, siendo la escasa calidad de atencion durante el parto un impedimento para hacer progresos. Enfoque Se desarrollo y probo un metodo de calculo de la calidad de la atencion materna y neonatal que podria aplicarse en una gran iniciativa nacional de gestion del rendimiento. La herramienta utilizo observaciones directas y revisiones de historiales medicos para puntuar la calidad en nueve dominios de atencion durante el parto. La herramienta se piloto y evaluo en visitas a los 18 hospitales mas importantes con responsabilidad para fomentar y coordinar esfuerzos de mejora de la calidad de un conglomerado de hospitales en Etiopia. Entre las primeras evaluacionesy las de seguimiento, el personal de una colaboracion nacional de calidad proporciono formacion hospitalaria sobre el parto. Marco regional Etiopia ha invertido en mejoras de la calidad de los hospitales durante mas de una decada y esta herramienta se ha, Introduction Maternal mortality remains high in most low-and middle-income countries, and poor quality of intrapartum care limits further progress. (1, 2) Pregnancy- or childbirth-related complications lead to more than 380 [...]

Many countries struggle to develop and implement strategies to monitor hospitals nationally. The challenge is particularly acute in low-income countries where resources for measurement and reporting are scarce. We examined the experience of developing and implementing a national system for monitoring the performance of 130 government hospitals in Ethiopia. Using participatory observation, we found that the monitoring system resulted in more consistent hospital reporting of performance data to regional health bureaus and the federal government, increased transparency about hospital performance and the development of multiple quality-improvement projects. The development and implementation of the system, which required technical and political investment and support, would not have been possible without strong hospital-level management capacity. Thorough assessment of the health sector's readiness to change and desire to prioritize hospital quality can be helpful in the early stages of design and implementation. This assessment may include interviews with key informants, collection of data about health facilities and human resources and discussion with academic partners. Aligning partners and donors with the government's vision for quality improvement can enhance acceptability and political support. Such alignment can enable resources to be focused strategically towards one national effort--rather than be diluted across dozens of potentially competing projects. Initial stages benefit from having modest goals and the flexibility for continuous modification and improvement, through active engagement with all stakeholders. De nombreux pays s'efforcent d'elaborer et de mettre en oeuvre des strategies pour controler les hopitaux a l'echelle nationale. C'est un defi de taille, en particulier pour les pays a faible revenu, qui disposent de peu de ressources pour effectuer des mesures et des comptes-rendus. Nous avons analyse l'experience qui a consiste a elaborer et mettre en oeuvre un systeme national de controle des performances de 130 hopitaux publics en Ethiopie. Des observations participatives ont revele que ce systeme de controle a entraine une communication plus systematique des donnees sur les performances aux bureaux regionaux de la sante et au gouvernement federal de la part des hopitaux, a ameliore la transparence concernant les performances de ces derniers et a permis d'elaborer plusieurs projets d'amelioration de la qualite, ^elaboration et la mise en oeuvre de ce systeme, qui ont necessite des investissements et des soutiens techniques et politiques, n'auraient pas ete possibles sans d'importantes capacites de gestion dans les hopitaux. Il peut etre utile, aux premiers stades de la conception et de la mise en oeuvre, d'evaluer de maniere approfondie l'ouverture au changement du secteur de la sante ainsi que son souhait de placer au premier plan la qualite des services hospitaliers. Cette evaluation peut s'appuyer sur des entretiens avec des informateurs cles, sur la collecte de donnees au sujet des etablissements de sante et des ressources humaines, ou encore sur une discussion avec des partenaires universitaires. Le fait d'associer des partenaires et des donateurs a l'objectif d'amelioration de la qualite vise par le gouvernement peut permettre de renforcer son acceptabilite ainsi que le soutien politique en la matiere. Cela peut permettre de faire converger les ressources de facon strategique vers un meme effort national, plutot que de les eparpiller dans des dizaines de projets potentiellement concurrents. Au cours des premieres phases, il est benefique d'avoir des objectifs modestes et de faire preuve de souplesse afin de permettre des modifications et une amelioration continues, par le biais d'un engagement actif aupres de l'ensemble des parties prenantes. Muchos paises tienen dificultades para desarrollar e implementar estrategias a nivel nacional para monitorizar los hospitales. El reto es especialmente complicado en paises de ingresos bajos donde los recursos para la medicion y la notificacion son escasos. Se examino la experiencia a la hora de desarrollar e implementar un sistema nacional para monitorizar el rendimiento de 130 hospitales del gobierno en Etiopia. Haciendo uso de una observacion participativa, se observo que el sistema de monitorizacion se tradujo en una notificacion de datos de rendimiento de los hospitales mas coherente a las oficinas de salud regionales y al gobierno federal, asi como un incremento en la transparencia sobre el rendimiento de los hospitales y el desarrollo de diferentes proyectos para la mejora de la calidad. El desarrollo y la implementacion de dicho sistema, que requeria de inversiones y soporte tanto tecnico como en materia de inversion, no hubieran sido posibles sin una fuerte habilidad de gestion a nivel hospitalario. Una meticulosa valoracion de la disposicion del sector sanitario a cambiar y del deseo de este a priorizar la calidad hospitalaria podria ser de gran ayuda en las primeras fases del diseno y la implementacion. Esta evaluacion podria incluir entrevistas con informadores clave, una recopilacion de datos sobre instalaciones sanitarias, recursos humanos y debates con asociados del mundo academico. Poner en consonancia la vision del gobierno sobre la mejora de la calidad con los asociados y contribuyentes puede hacer aumentar la aceptacion y el apoyo politico. Dicho alineamiento puede permitir una focalizacion estrategica de los recursos respecto a un solo esfuerzo nacional, antes que esparcirlo en docenas de proyectos potencial mente conflictivos. Las fases iniciales son las principales beneficiadas de tener objetivos modestos y flexibilidad para modificar y mejorar de forma continua, a traves de un compromiso activo con todos los accionistas., Introduction Improvement in the quality of hospital care is a fundamental aspect of health system strengthening (1-4) that is directly linked to the service delivery dimension of the World Health [...]

Objective To conduct a cross-national comparative study of the prevalence and correlates of female genital cutting (FGC) practices and beliefs in western Africa. Methods Data from women who responded to the Multiple Indicator Cluster Surveys between 2005 and 2007 were used to estimate the frequencies of ever having been circumcised, having had a daughter circumcised, and believing that FGC practices should continue. Weighted logistic regression using data for each country was performed to determine the independent correlates of each outcome. Findings The prevalence of FGC was high overall but varied substantially across countries in western Africa. In Sierra Leone, Gambia, Burkina Faso and Mauritania, the prevalence of FGC was 94%, 79%, 74% and 72%, respectively, whereas in Ghana, Niger and Togo prevalence was less than 6%. Older age and being Muslim were generally associated with increased odds of FGC, and higher education was associated with lower odds of FGC. The association between FGC and wealth varied considerably. Burkina Faso was the only country in our study that experienced a dramatic reduction in FGC prevalence from women (74%) to their daughters (25%); only 14.2% of the women surveyed in that country said that they believe the practice should continue. Conclusion The prevalence of FGC in western Africa remains high overall but varies substantially across countries. Given the broad range of experiences, successful strategies from countries where FGC is declining may provide useful examples for high-prevalence countries seeking to reduce their own FGC practices. [TEXT NOT REPRODUCIBLE IN ASCII.] Mutilations genitales feminines: pratiques et croyances actuelles en Afrique de l'Ouest Objectif Realiser une etude comparative transnationale de la prevalence et des indicateurs des pratiques et croyances en matiere de mutilations genitales feminines (MGF) en Afrique de l'Ouest. Methodes Les donnees fournies par des femmes ayant repondu aux enquetes en grappes a indicateurs multiples entre 2005 et 2007 ont servi a estimer la frequence avec laquelle elles avaient ete excisees, avaient fait exciser une ou plusieurs de leurs filles et pensaient que les pratiques de MGF devaient se poursuivre. Une regression logistique ponderee a ete realisee afin de determiner les indicateurs autonomes de chaque resultat. Resultats La prevalence des MGF etait generalement elevee mais variait de maniere significative d'un pays d'Afrique de l'Ouest a l'autre. En Sierra Leone, Gambie, Burkina Faso et Mauritanie, la prevalence des MGF etait de 94%, 79%, 74% et 72%, respectivement, alors qu'au Ghana, Niger et Togo, cette prevalence etait inferieure a 6%. Un age plus avance et le fait d'etre musulmane constituaient des facteurs generalement associes a des risques accrus de MGF et un degre d'education plus eleve etait associe a des risques plus faibles. L'association entre MGF et aisance financiere variait considerablement. Le Burkina Faso etait le seul pays de notre etude a avoir note une diminution spectaculaire des MGF des femmes (74%) a leurs filles (25%); seules 14,2% des femmes interrogees dans ce pays ont declare penser que cette pratique devait se poursuivre. Conclusion La prevalence des MGF en Afrique de l'Ouest reste generalement elevee mais varie de maniere significative d'un pays a l'autre. Compte tenu du large eventail d'experiences, des strategies reussies dans des pays ou les MGF sont en baisse peuvent fournir des exemples utiles a des pays a forte prevalence desireux de diminuer leurs propres pratiques de MGF. [TEXT NOT REPRODUCIBLE IN ASCII.] Mutilacion genital femenina: practicas actuales y creencias en Africa occidental Objetivo Llevar a cabo un estudio comparativo entre paises de artica occidental sobre la prevalencia y correlacion de las practicas de mutilacion genital femenina (MGF) y las creencias relacionadas. Metodos Se emplearon los datos procedentes de las mujeres que respondieron a las Encuestas de Indicadores Multiples por Conglomerados entre 2005 y 2007 para calcular el porcentaje de mujeres que habian sido sometidas a una ablacion, el de hijas de dichas mujeres que habian sido sometidas a una ablacion y la creencia de que las practicas de MGF deberian mantenerse. Se realizo una regresion logistica ponderada empleando los datos procedentes de cada pais para determinar las correlaciones independientes de cada resultado. Resultados La prevalencia de la MGF fue alta en general, si bien variaba de manera sustancial en los diversos paises de africa occidental. En Sierra Leona, Gambia, Burkina Faso y Mauritania, la prevalencia de la MGF fue de un 94%, 79%, 74% y 72%, respectivamente, mientras que en Ghana, Niger y Togo la prevalencia fue inferior al 6%. Una edad mas avanzada y la condicion de musulmana se asociaron generalmente a una mayor probabilidad de haber sufrido una MGF, mientras que se asocio una educacion superior a una menor probabilidad de MGF. La asociacion entre MGF y riqueza variaba ostensiblemente. Burkina Faso fue el unico pais dentro del estudio que experimento una reduccion drastica en la prevalencia de la MGF entre las madres (74%) y las hijas (25%). Solo el 14,2% de las mujeres encuestadas en dicho pais afirmaron considerar que debia continuarse con dicha practica. Conclusion La prevalencia de la MGF en affica occidental sigue siendo elevada en general, si bien varia sustancialmente entre los diversos paises. Teniendo en consideracion la amplia variedad de experiencias, las estrategias fructiferas en paises donde la MGF esta descendiendo podrian servir de ejemplo util a los paises con una mayor prevalencia que deseen reducir sus practicas de MGF., Introduction More than 100 million girls and women have undergone female genital cutting (FGC, also known as 'female circumcision'), and more than 3 million female infants and children are at [...]

One third of older adults fall each year, placing them at risk for serious injury, functional decline, and health care utilization. Despite the availability of effective preventive approaches, policy and clinical efforts at preventing falls among older adults have been limited. In this article we present the burden of falls, review evidence concerning the effectiveness of fall-prevention services, describe barriers for clinicians and for payers in promoting these services, and suggest strategies to encourage greater use of these services. The challenges are substantial, but strategies for incremental change are available while more broad-based changes in health care financing and clinical practice evolve to better manage the multiple chronic health conditions, including falls, experienced by older Americans. Key Words: Falls interventions, Falls prevention, Fall-risk evaluation, Medicare, Preventive approaches

Objectives. The purpose of this study was to investigate the association between involuntary job loss among workers nearing retirement and long-term changes in depressive symptoms. Methods. Analyzing data from the first four waves (1992-1998) of the Health and Retirement Survey, we used longitudinal multiple regression in order to assess whether involuntary job loss between Wave 1 and Wave 2 was associated with depressive symptoms at Wave 3 and Wave 4. The study sample included 231 workers who had experienced job loss in the Wave 1-Wave 2 interval and a comparison group of 3,324 nondisplaced individuals. We analyzed the effect of job loss on depressive symptoms both in the full study sample and in subsamples determined by wealth. Results. Among individuals with below median net worth, Wave 1-Wave 2 involuntary job loss was associated with increased depressive symptoms at Wave 3 and Wave 4. We found no effect of involuntary job loss for high net worth individuals at the later survey waves. Discussion. Our findings identify older workers with limited wealth as an important group for which the potential effect of involuntary job separation in the years preceding retirement is ongoing (enduring) adverse mental health.

* BACKGROUND Although nurses are ideally situated to facilitate communication about prognosis and hospice referral among patients, patients family members, and hospital staff, nurses do not always assume this task. [...]

Objectives. This study estimates the consequences of older husbands' involuntary job loss for their wives' mental health. Methods. Using longitudinal data from the 1992, 1994, and 1996 waves of the Health and Retirement Study, multivariate regression models were estimated to measure the impact of older husbands' involuntary job loss on wives' mental health. We created two longitudinal data sets of two waves each to use in our analysis. The first data set, or period, combined Waves 1 and 2 of the Health and Retirement Study and described the 1992-1994 experience of spouse pairs in our sample. It included the wives of 55 husbands who experienced involuntary job loss between these survey dates and a comparison group of wives of 730 continuously employed husbands. The second data set described the 1994-1996 experience of couples. In particular, it included the wives of an additional 38 husbands who were displaced from their jobs between Waves 2 and 3, and a comparison group of wives of 425 husbands who were continuously employed from 1994 to 1996. Results. Husbands' involuntary job loss did not have a statistically significant effect on wives' mental health. We found no evidence that changes in husbands' depressive symptoms modified the effect of his job loss on wives' mental health. In the first period only, the effect of husbands' job loss on wives' mental health was more pronounced for wives who were more financially satisfied at baseline. Discussion. There is limited evidence among this cohort that husbands' job loss increases wives' subsequent depressive symptoms. However, the effect of husbands' job loss on wives' mental health appears to be magnified when wives report being financially satisfied pre-job loss. This suggests that, for subgroups of older couples, mental health services specifically targeted at displaced men should also be made available to wives.

Objectives. The purpose of this study was to develop a patient-centered measure of treatment preference applicable across a range of diseases and treatment decisions. Methods. Instrument development was based on previous research supplemented by open-ended interviews and focus groups. Psychometric properties of the instrument were determined by administration to 125 persons aged 60 or older with a limited life expectancy secondary to congestive heart failure, chronic obstructive pulmonary disease, or cancer. Test-retest and inter-rater reliability were established using intraclass correlation coefficients. Construct validity was established by examining associations of the measure with a single-item question regarding treatment goals and with age, ethnicity, and functional impairment, characteristics known to be associated with preferences. The Willingness to Accept Life-Sustaining Treatment instrument (WALT) consists of 6 scenarios in which respondents weigh treatment burden against treatment outcomes expressed in terms of the likelihood of different health states and length of life following treatment. Results. Inter-rater reliability ranged from .73 to .95 and test-retest reliability from .49 to .93. WALT scores were significantly associated with a simpler measure of preference and with age, ethnicity, and functional impairment. Conclusions. The WALT measures patients' treatment preferences, assessed in the context of treatment burden and multiple aspects of treatment outcome with sound psychometric properties.

Previous evaluative studies of outpatient geriatric assessment have focused on a limited set of outcomes related to functioning, health services utilization, and costs. The purpose of this study was to identify important goals for care as described by patients and family caregivers being cared for in this setting. Using a cross-section of 226 consecutive sets of patients and their primary family caregivers, physicians, and case managers, goals of care for individual patients were coded from open-ended interview responses. The most common categories of goals expressed by family caregivers were obtaining education and referrals (57.5%) and improving social and family relationships (53.0%). The process of establishing and meeting such goals should be explicitly included in the design of future evaluations of outpatient geriatric assessment.

Objective. To estimate the effect of involuntary job loss on subsequent alcohol consumption by older workers in the United States. Methods. Using longitudinal data from the 1992 and 1994 waves of the Health and Retirement Survey, the authors estimated multivariate models to assess the impact of involuntary job loss on subsequent alcohol use. Two outcomes were investigated: reported daily alcohol consumption and onset of drinking. The analysis sample included 207 workers who experienced involuntary job loss between survey dates and a comparison group of 2,866 continuously employed workers. Results. After baseline alcohol consumption and a variety of socioeconomic and illness-related covariates were controlled, involuntary job loss was not associated (p [is greater than] .05) with number of daily drinks consumed at follow-up. However, among those who did not consume alcohol at baseline, individuals who suffered involuntary job loss were twice as likely as continuously employed individuals to start drinking by follow-up (OR = 2.01; CI = 1.06-3.80). The majority of those who began drinking at follow-up reported drinking less than 1 drink per day. Discussion. The findings provide evidence of a significant relationship between job loss and subsequent alcohol use among baseline nondrinkers. However, the magnitude of the changes in drinking was quite modest.

Objectives. To estimate the health consequences of involuntary job loss among older workers in the United States. Methods. Using longitudinal data from the 1992 and 1994 waves of the Health and Retirement Survey, multivariate regression models were estimated to assess the impact of involuntary job loss on both physical functioning and mental health. Our analysis sample included 209 workers who experienced involuntary job loss between survey dates and a comparison group of 2,907 continuously employed workers. Results. The effects of late-life involuntary job loss on both follow-up physical functioning and mental health were negative and statistically significant (p [is less than] .05), even after baseline health status and sociodemographic factors were controlled for. Among displaced workers, reemployment was positively associated with both follow-up physical functioning and mental health, whereas the duration of joblessness was not significantly associated with either outcome. Discussion. The findings provide evidence of a causal relationship between job loss and morbidity among older workers. This relationship is reflected in both poorer physical functioning and mental health for workers who experience involuntary job loss. In addition to the economic consequences of worker displacement, there may be important health consequences of job loss, especially among older workers.

The process of setting goals for medical care in the context of chronic disease has received little attention in the medical literature, despite the importance of goal-setting in the achievement of desired outcomes. Using qualitative research methods, this paper develops a theory of goal-setting in the care of patients with dementia. The theory posits several propositions. First, goals are generated from embedded values but are distinct from values. Goals vary based on specific circumstances and alternatives whereas values are person-specific and relatively stable in the face of changing circumstances. Second, goals are hierarchical in nature, with complex mappings between general and specific goals. Third, there are a number of factors that modify the goal-setting process, by affecting the generation of goals from values or the translation of general goals to specific goals. Modifying factors related to individuals include their degree of risk-taking, perceived self-efficacy, and acceptance of the disease. Disease factors that modify the goal-setting process include the urgency and irreversibility of the medical condition. Pertinent characteristics of the patient-family-clinician interaction include the level of participation, control, and trust among patients, family members, and clinicians. The research suggests that the goal-setting process in clinical medicine is complex, and the potential for disagreements regarding goals substantial. The nature of the goal-setting process suggests that explicit discussion of goals for care may be necessary to promote effective patient-family-clinician communication and adequate care planning. Keywords: Goals; Doctor-patient relationship; Communication; Dementia

Background: Management training is fundamental to developing human resources for health. Particularly as Liberia revives its health delivery system, facility and county health team managers are central to progress. Nevertheless, such management skills are rarely prioritized in health training, and sustained capacity building in this area is limited. We describe a health management delivery program in which a north and south institution collaborated to integrate classroom and field-based training in health management and to transfer the capacity for sustained management development in Liberia. Methods: We developed and implemented a 6-month training program in health management skills (i.e. strategic problem solving, financial management, human resource management and leadership) delivered by Yale University and Mother Patern College from Liberia, with support from the Clinton HIV/AIDS Initiative. Over three 6-month cycles, responsibility for course instruction was transferred from the north institution to the south institution. A selfadministered survey was conducted of all participants completing the course to measure changes in self-rated management skills, the degree to which the course was helpful and met its stated objectives, and faculty members' responsiveness to participant needs as the transfer process occurred. Results: Respondents (n = 93, response rate 95.9%) reported substantial improvement in self-reported management skills, and rated the helpfulness of the course and the degree to which the course met its objectives highly. Levels of improvement and course ratings were similar over the three cohorts as the course was transferred to the south institution. We suggest a framework of five elements for implementing successful management training programs that can be transferred and sustained in resource-limited settings, including: 1) use a shortcourse format focusing on four key skill areas with practical tools; 2) include didactic training, on-site projects, and on-site mentoring; 3) collaborate with an in-country academic institution, willing and able to scale-up and maintain the training; 4) provide training for the in-country academic faculty; and 5) secure Ministry-level support to ensure participation. Conclusion: Our findings demonstrate key elements for scaling up and replicating educational initiatives that address management skills essential for long-term health systems strengthening in resource-poor settings. [ABSTRACT FROM AUTHOR]

Objective: To estimate the effect of spousal depressive symptoms and physical health on respondents' depressive symptoms in a national sample of older married couples. Method: We used data on 5, 035 respondent husbands and wives from the 1992 and 1994 waves of the Health and Retirement Survey. Multivariate regression models were estimated to examine the impact of spousal depressive symptoms and physical health on respondents' depressive symptoms. Results: Adjusting for respondent mental and physical health and sociodemographic traits, having a spouse with more depressive symptoms was associated with significantly higher follow-up depressive symptoms in the respondent (p < .001). Controlling for spousal depressive symptoms, a decline in the spouses' physical health was associated with a significant reduction in respondent depressive symptoms (p < .05). Discussion: Our findings suggest that health care providers treating older adults should be sensitive to the possibility that spouses may be affected when clients suffer poor mental or physical health. [ABSTRACT FROM AUTHOR]