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Highlights • Analyzes citizen actions, contextual conditions and outcomes in 29 cases of initiatives for health system accountability in Guatemala. • Highlights pathways involving network building, monitoring and engagement with different authorities and how they lead to responsive action. • Iterative cycles of collective action are critical for activating the power of marginalized citizens to demand accountability from authorities. • Initiatives employ constructive and adversarial engagement strategies to achieve solutions to the health system failures they face. Abstract Strengthening citizen-led accountability initiatives is a critical rights-based strategy for improving health services for indigenous and other marginalized populations. As these initiatives have gained prominence in health and other sectors, there is great interest in how they operate and what makes them effective. Scholarly focus is shifting from measuring the efficacy of their tools and tactics to deepening understanding of the context-sensitive pathways through which change occurs. This paper examines how citizen-led initiatives' actions to strengthen grassroots networks, monitor health services and engage with authorities interact with local sociopolitical conditions and contribute to accountability achievements for indigenous populations in rural Guatemala. We used qualitative comparative analysis to first systematize and score structured qualitative monitoring data gathered in 29 municipal-level initiatives, and then analyze patterns in the presence of different forms of citizen action, contextual conditions and accountability outcomes across cases. Our study identifies pathways of collective action through which citizen-led initiatives bolster their power to engage and negotiate with authorities and bring about solutions to some of the health system deficiencies that they face. While constructive engagement is widely advocated as the most effective approach to interaction with authorities, our study indicates that success depends on wider processes of community mobilization. To overcome the power asymmetries that marginalized groups face when engaging with authorities, iterative processes of network building and participatory monitoring as well as persistence in their demands are critical. These processes further provide an enabling environment for moving beyond the local and projecting indigenous voices to engage with authorities at higher governance levels. Initiatives also applied adversarial legal action as an alternative engagement strategy that contributed to bolster citizen power. Our findings indicate the potential of collective power generated by the actions of citizen-led initiatives to enable marginalized populations to hold authorities accountable for health system failures. [ABSTRACT FROM AUTHOR]

Objectives: To ascertain household coverage achieved by Swaziland's national community health worker (CHW) programme and differences in household coverage across clients' sociodemographic characteristics.Methods: Household survey from June to September 2015 in two of Swaziland's four administrative regions using two-stage cluster random sampling. Interviewers administered a questionnaire to all household members in 1542 households across 85 census enumeration areas.Results: While the CHW programme aims to cover all households in the country, only 44.5% (95% confidence interval: 38.0% to 51.1%) reported that they had ever been visited by a CHW. In both uni- and multivariable regressions, coverage was negatively associated with household wealth (OR for most vs. least wealthy quartile: 0.30 [0.16 to 0.58], P < 0.001) and education (OR for >secondary schooling vs. no schooling: 0.65 [0.47 to 0.90], P = 0.009), and positively associated with residing in a rural area (OR: 2.95 [1.77 to 4.91], P < 0.001). Coverage varied widely between census enumeration areas.Conclusions: Swaziland's national CHW programme is falling far short of its coverage goal. To improve coverage, the programme would likely need to recruit additional CHWs and/or assign more households to each CHW. Alternatively, changing the programme's ambitious coverage goal to visiting only certain types of households would likely reduce existing arbitrary differences in coverage between households and communities. This study highlights the need to evaluate and reform large long-standing CHW programmes in sub-Saharan Africa. [ABSTRACT FROM AUTHOR]

Background: System-wide training initiatives to support and implement evidence-based practices (EBPs) in behavioral health systems have become increasingly widespread. Understanding more about organizations who do not participate in EBP training initiatives is a critical piece of the dissemination and implementation puzzle if we endeavor to increase access in community settings.Methods: We conducted 30 1-h semi-structured interviews with leaders in non-participating agencies who did not formally participate in system-wide training initiatives to implement EBPs in the City of Philadelphia, with the goal to understand why they did not participate.Results: We found that despite not participating in training initiatives, most agencies were adopting (and self-financing) some EBP implementation. Leadership from agencies that were implementing EBPs reported relying on previously trained staff to implement EBPs and acknowledged a lack of emphasis on fidelity. Most leaders at agencies not adopting EBPs did not have a clear understanding of what EBP is. Those familiar with EBPs in agencies not adopting EBPs reported philosophical objections to EBPs. When asked about quality assurance and treatment selection, leaders reported being guided by system audits.Conclusions: While it is highly encouraging that many agencies are adopting EBPs on their own, significant questions about fidelity and implementation success more broadly remain. [ABSTRACT FROM AUTHOR]

This article examines the function of community-based organizations in engaging citizens in planning healthy built environments in urban neighbourhoods. Research on the 3-year Green, Active, Healthy Neighbourhoods (GAHN) initiative, spearheaded by a city-wide umbrella group and local organizations in four boroughs of Montreal found that in activating citizen participation, the role of organizations was significant in four dimensions: (i) mobilizing to generate awareness and interest; (ii) giving voice to problems and solutions; (iii) pooling citizens' and professionals' knowledge; and (iv) maintaining participation in implementation. Organizations involved in GAHN provided creative tools and processes for citizens' participation, which were valued by planners and local authorities, but collaborative participation was difficult beyond the exploratory and diagnostic dimensions. This study points to the challenges in sustaining collaboration and having influence. Organizations need to maintain pressure, conserve independence and renew linkages with citizens to shift urban planning practices from car-dominated to people-centred development. [ABSTRACT FROM AUTHOR]

Decisions on health-related risks affect many people personally. The public debate on hospital planning is therefore especially emotional and conflict-ridden. Due to the aging population and the high costs of constantly improving medical care, the question arises in many German rural areas as to which hospitals can be kept and developed further and which ones should be closed. The new approach of the present state government of Baden-Württemberg in Germany, in collaboration with the University of Stuttgart and the State Health Office Baden-Württemberg, is to apply citizen participation to prepare this type of decision. The design of this type of public participation process is based on the criteria of mediation (including open decision-making scope, opportunity for discussion in the protected context of the working group, as well as disclosure of all information and transparency of the results toward the public). This approach has proven useful for conducting dialogs in areas with potential conflict. Based on the experiences from this hospital participation process, further recommendations for an effective, efficient and fair participation processes could be derived. The case demonstrates that adequate and structured involvement processes are capable of delivering sustainably acceptable results even in difficult decision-making processes. [ABSTRACT FROM AUTHOR]

Mano a Mano (Spanish translation: "Hand to Hand") is a nonprofit organization that is working in partnership with underserved Bolivian communities to cocreate medical infrastructures and to improve health. Using community-based participatory research (CBPR) methods, Mano a Mano engages local government and community leaders, health care providers, educators, and ordinary citizens in a manner that taps local strengths and resources to allow all participants to work together to realize this mission. After describing Bolivia's call for improved access to high quality care in its poor and underserved rural areas, we outline the Mano a Mano's CBPR approach and sequence to answer this call, the culmination of its efforts to date (including the establishment of 119 health care facilities), lessons learned, and next steps in the formal evaluation and extension of this collaborative work. [ABSTRACT FROM AUTHOR]

Virtual communities for those who self-injure (SI) are increasingly popular and involve Internet communication technologies including e-message boards. The social and emotional support of an accepting virtual community may facilitate individual recovery from SI. Via self-report data, this study describes individuals who participate in virtual communities for those who SI and implications for e-health communities. Sixty-seven individuals who participate in virtual communities responded to ten open-ended questionnaire items posted on two e-message boards for those who SI. Participants reported a variety of strategies of self-harm. The majority indicated that they SI in response to emotional distress. Almost half reported visiting the boards at least once a day. More than half indicated that their SI decreased in frequency since joining virtual communities. Virtual communities for those who SI provide information on recovery, emotional support, and a sense of community to individuals isolated by their behavior. Improved community e-health services may include peer-to-peer online support. [ABSTRACT FROM AUTHOR]

Although disadvantaged women are the targets of marriage programs, little attention has been paid to women's marriage constraints and their views of marriage. Drawing on an exchange framework and using qualitative data collected from single women participating in a marriage initiative, we introduce the concept of marriageable women—the notion that certain limitations may make women poor marriage partners. Like their male counterparts, we find women also possess qualities that are not considered assets in the marriage market, such as economic constraints, mental and physical health issues, substance use, multiple partner fertility, and gender distrust. We also consider how women participating in a marriage program frame their marriage options, whereas a few opt out of the marriage market altogether. [ABSTRACT FROM AUTHOR]

In 1994, the National Institute of Environmental Health Sciences (NIEHS) initiated a program to address communication gaps between community residents, researchers and health care providers in the context of disproportionate environmental exposures. Over 13 years, together with the Environmental Protection Agency and National Institute for Occupational Health and Safety, NIEHS funded 54 environmental justice projects. Here we examine the methods used and outcomes produced based on data gathered from summaries submitted for annual grantees meetings. Data highlight how projects fulfilled program objectives of improving community awareness and capacity and the positive public health and public policy outcomes achieved. Our findings underscore the importance of community participation in developing effective, culturally sensitive interventions and emphasize the importance of systematic program planning and evaluation. (AmJ Public Health. 2009;99:S517-S525. doi:10. 2105/AJPH.2009.174557) [ABSTRACT FROM AUTHOR]

It is never easy to speak about the best ways to promote health in a multicultural geographic space such as the Colombian Department of Valle del Cauca, because it is almost inevitable to resort to the prescribed "formulae" established by the central order to satisfy the expectations of the policy makers and budgetary authorities. In this article we outline an alternative way to systematize community experiences related to information, education, and communication, as well as highlighting the importance of including participatory proposals and methodologies in order to recover local knowledge and wisdom to create wider and more sustainable strategies different to those established by conventional media campaigns which are almost always proposed from academic and disciplinary scenarios which dodge the rich and varied field of communications. [ABSTRACT FROM AUTHOR]

This article discusses the failure to implement the goals of the 1978 Alma-Ata, Kazakhstan Declaration on public health services accessibility and the 2000 United Nations Millennium Project goals. The role that primary health care services will play in the eventual achievement of these goals is addressed. The goals are described in terms of their larger ideals, such as health for all, and their quantifiable aims, such as measurable reductions in child mortality. Challenges related to the integration of primary health care within the public health infrastructures of developing countries are addressed. administration and the development of meaningful community participation in health care are described as two issues relating to the implementation of public health goals. INSETS: Panel 1: Research priorities for primary health care based on...;Panel 2: Actions to increase commitment and resources for....

This article discusses the role of community participation in medical care for mothers and their newborn children. The role of community participation in public health administration is framed as a goal established by the 1978 Alma-Ata, Kazakhstan Declaration on primary care in public health. Controversy regarding the relative importance of targeted interventions and community based health services in international aid to medical care is described. Community based efforts to develop public health interventions are framed in terms of their small scale compared to commodity based approaches that provide products such as mosquito netting and oral rehydration formula to treat diarrhoea. INSETS: Panel 1: Projects in rural India and Kenya which influenced...;Panel 2: Building community empowerment;Panel 3: Case study of how women's groups are addressing first....

This article assesses the implementation of health care reforms proposed by the Alma-Ata, Kazakhstan Declaration on health services accessibility in 1978. These principles included equal access to treatment, social justice, and health care for all. Changes in the provision of primary care are analysed in terms of the changing contexts in which public health services are administered. Issues arising from the development of integrated health systems and an increasing focus on evidence-based approaches to medicine are considered. The increasing importance of community participation in medical care is noted. The importance of increased access to medical technology in the developing world is encouraged. INSETS: Panel 1: Declaration of Alma-Ata International Conference on...;Panel 3: Summary of the main programmes and tasks within the....

Mental health services are required to involve family, carers, and service users in the delivery and development of mental health services but how this can be done in routine practice is challenging. One potential solution is to prescribe practice standards or clear expectation relating to family involvement. This paper describes practice standards introduced to an adult mental health service and a study that aimed to evaluate the impact of the standards on practice. Hospital and community files were audited before and after the introduction of standards for evidence of participation and surveys of carers and consumers relating to the quality of participation were undertaken. Increases in documented carer participation were found, particularly in relation to treatment or care planning. The expressed needs relating to participation varied in hospital and community settings. The majority of carers and service users were satisfied with their level of participation. The introduction of practice standards is an acceptable, inexpensive, and feasible way of improving the quality of family and carer participation, but gains may be modest. [ABSTRACT FROM AUTHOR]

This article, part of the thesis project "Practices and representations about the processes of health and disease in the population of Azampay", analyzes how different health caring spaces are combined and which factors are regarded by the inhabitants of this town when they choose the type of treatment to confront an illness. Azampay is a rural town 50 km away from Belen city with a population of 230. There is a combined use of various therapeutic resources: household responses (remedies that are at hand in every family), the attention of healers within or outside the town, local medical services (the village has a dispensary where two nurses provide care and every 15 days it is attended by a doctor) and public or private medical services of the cities of Belen and Catamarca. I work with the information constructed in interviews (to lay adults and to staff of the different levels of care used by them: informal healers, nurses and doctors), observations and casual conversations with the inhabitants in subsequent fieldworks (2004, 2005, 2006 and 2007). [ABSTRACT FROM AUTHOR]

The author presents an editorial responding to the article "Addressing Health Disparities Through Deliberative Methods: Citizens' Panels for Health Equity" in the current issue. She mentions the level of health disparities in the U.S., the planning for community health services, and the importance of citizen participation.

This article focuses on a community-initiated intervention to reduce HIV and STD transmission among Latino men, who have been disproportionally affected in the U.S. Community-based participatory research was used in partnership with HoMBReS, a sexual risk reduction intervention, in the fast-growing Latino community in predominantly rural Chatham County in central North Carolina. This study employs an innovative strategy using lay health advisors (LHAs) working within existing social networks, behavior change models employing social cognitive theory and empowerment education and strong partnership approaches to develop, implement, assess, revise, and distribute an HIV/STD prevention intervention. LHA training and lessons learned from the training are described. HoMBReS is an ongoing intervention pilot study.

Most estimates of the cost of informal caregiving in patients with Alzheimer's disease (AD) remain cross-sectional. Longitudinal estimates of informal caregiving hours and costs are less frequent and are from assessments covering only short periods of time. The objectives of this study were to estimate long-term trajectories of the use and cost of informal caregiving for patients with AD and the effects of patient characteristics on the use and cost of informal caregiving. The sample is drawn from the Predictors Study, a large, multicenter cohort of patients with probable AD, prospectively followed annually for up to 7 years in three university-based AD centers in the United States (n=170). Generalized linear mixed models were used to estimate the effects of patient characteristics on use and cost of informal caregiving. Patients' clinical characteristics included cognitive status (Mini-Mental State Examination), functional capacity (Blessed Dementia Rating Scale (BDRS)), comorbidities, psychotic symptoms, behavioral problems, depressive symptoms, and extrapyramidal signs. Results show that rates of informal care use and caregiving hours (and costs) increased substantially over time but were related differently to patients' characteristics. Use of informal care was significantly associated with worse cognition, worse function, and higher comorbidities. Conditional on receiving informal care, informal caregiving hours (and costs) were mainly associated with worse function. Each additional point on the BDRS increased informal caregiving costs 5.4%. Average annual informal cost was estimated at $25,381 per patient, increasing from $20,589 at baseline to $43,030 in Year 4. [ABSTRACT FROM AUTHOR]

Objective: The aim of this paper is to trace evolution of mental health system in Poland. Method: Available Polish literature and fundamental policy documents including mental health legislation are reviewed and major milestones in this evolution identified and then discussed against the background of political and social developments. Results: The mental health system evolved since the beginning of the 1970s from large hospitals towards community-based care. It was found that the changes were rather slow due to financial shortages and lack of clear demand from users. Recent transitions offer opportunities to increase impact of users and their families. On the other hand, however, introduction of health insurance system reduces prospects for well co-ordinated mental health policy and may lead to inequalities in access to services. Conclusion: It can be concluded that evolution of mental health services has been influenced by prevailing ideologies as much as by technical and professional considerations. [ABSTRACT FROM AUTHOR]

Objective: To describe mental health care needs and challenges across the WHO European region of 51 nations. Method: Based on morbidity and mortality data from HFA Statistical Database and Health21, the policy framework of WHO Europe, major trends in mental health care needs, psychiatric reform and mental health promotion are discussed. Results: There is a mortality crisis related to mental ill health in Eastern European populations of transition. Destigmatization is required to improve early intervention and humanization of services, and national mental health audits are needed to create the basis for national mental health planning, implementation and monitoring. There are both problems and advances in service restructuring, and comprehensive mental health promotion programmes, preventive and monitoring strategies are required. Conclusion: Partnerships between national and international organizations, especially WHO and the European Union, have to be strengthened to make progress on the way to integrated community mental health services. [ABSTRACT FROM AUTHOR]

Describes Community Mobilization Framework, a model for the prevention of HIV in women and infants on a community level. Approaches to HIV prevention intervention changes on a community level; Fundamental bases of the Community Mobilization Framework; Characterization of the variety of the individual, social and organizational roles and relationships in the community.

Documents the experiences of the AIDS Community Demonstration Projects in recruiting networks of community members to deliver HIV prevention interventions to high risk populations in the United States. Incentives given to networkers; Intervention materials distributed; Recruitment and training of networkers; Safety issues during distribution.

The article discusses an Ecuadorean public health campaign to reduce infant intestinal illness due to parasites, and the role of the Centro Internacional de Estudios Superiores de Comunicación para América Latina (CIESPAL). It notes the initiative's sponsors, describes some of its components, and considers CIESPAL's role in researching and designing various communication and educational products such as posters, stories and audiovisual materials. Also noted is CIESPAL's involvement in measuring the impact of the campaign.

The health status of Aboriginal and Torres Strait Islander peoples continues to be significantly poorer than Australia's general population. Clearly there is a need for change, hence the renewed interest in transitioning to a community control model for health services as a health intervention. Yet this requires a significant change management process, which is a process developed using Western business philosophies, and may not be applicable for community-controlled services that need to operate within the Aboriginal cultural domain. This paper examines the literature on organisational change management processes, and features of Aboriginal community-controlled health organisations and Aboriginal management styles. It identifies challenges and synergies that can be used to inform more effective transition processes to a community-control model for health services. The findings also highlight the need for a fundamental systems change approach to achieve such major reform agendas through the creation of a "collective responsibility" to achieve the vision for change, utilising participatory change management processes both internally and externally. [ABSTRACT FROM AUTHOR]