Protocol for the ROSE sustainment (ROSES) study, a sequential multiple assignment randomized trial to determine the minimum necessary intervention to maintain a postpartum depression prevention program in prenatal clinics serving low-income women

Background: More research on sustainment of interventions is needed, especially return on investment (ROI) studies to determine cost-benefit trade-offs for effort required to sustain and how much is gained when effective programs are sustained. The ROSE sustainment (ROSES) study uses a sequential multiple assignment randomized (SMART) design to evaluate the effectiveness and cost-effectiveness of a stepwise approach to sustainment of the ROSE postpartum depression prevention program in 90 outpatient clinics providing prenatal care to pregnant women on public assistance. Postpartum depression (PPD) is common and can have lasting consequences. Outpatient clinics offering prenatal care are an opportune place to provide PPD prevention because most women visit while pregnant. The ROSE (Reach Out, Stay Strong, Essentials for mothers of newborns) program is a group educational intervention to prevent PPD, delivered during pregnancy. ROSE has been found to reduce cases of PPD in community prenatal settings serving low-income pregnant women. Methods: All 90 prenatal clinics will receive enhanced implementation as usual (EIAU; initial training + tools for sustainment). At the first time at which a clinic is determined to be at risk for failure to sustain (i.e., at 3, 6, 9, 12, and 15 months), that clinic will be randomized to receive either (1) no additional implementation support (i.e., EIAU only), or (2) low-intensity coaching and feedback (LICF). If clinics receiving LICF are still at risk at subsequent assessments, they will be randomized to either (1) EIAU + LICF only, or (2) high-intensity coaching and feedback (HICF). Additional follow-up interviews will occur at 18, 24, and 30 months, but no implementation intervention will occur after 18 months. Outcomes include (1) percent sustainment of core program elements at each time point, (2) health impact (PPD rates over time at each clinic) and reach, and (3) ROI (costs and cost-effectiveness) of each sustainment step. Hypothesized mechanisms include sustainment of capacity to deliver core elements and engagement/ownership. Discussion: This study is the first randomized trial evaluating the ROI of a stepped approach to sustainment, a critical unanswered question in implementation science. It will also advance knowledge of implementation mechanisms and clinical care for an at-risk population

It's worse than the war: Telling everyday danger in postwar San Salvador.

This dissertation centers on fragments of Salvadoran postwar experience entextualized as crime narratives, shared in everyday conversation and absorbed into newspaper articles and television reports produced in the mid-1990s. In 1996, El Salvador's murder rate surpassed wartime levels and showed it to be the most violent in Latin America. This thesis thus asks, what does unremitting, everyday violence mean to people in the context of transition from war? It argues that the circulation of stories of danger and violence, occurring at the intersection of self and other, citizen and state, the powerful and powerless, became one way to talk about and evaluate the postwar transition in El Salvador. It suggests that the joint production of such stories among Salvadorans worked to reshape memories of the war and to yield emergent understandings of social relations in the postwar period. The thesis is based on research conducted in San Salvador between 1994 and 1999, using ethnographic field methods, mass media and literature research, and tape-recorded interviews. Drawing on anthropological and linguistic anthropological theories of semiotics, performance, narrative and social memory, this work offers a culturally focused way of theorizing about crime, violence and social relations, and contributes to an ethnographic perspective on postwar transition and human rights in Latin America. Its implications reach far beyond its immediate context. Crime rates continue to rise not only throughout Latin America but around the globe; post-conflict, post-authoritarian transitions are often accompanied by widespread non-political violence.Ph.D.Cultural anthropologyLatin American historySocial SciencesUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/130200/2/3042137.pd

Delineating Quality Indicators of Inpatient Psychiatric Hospitalization.

BACKGROUND: Assuring quality care is critical to the well-being and recovery of individuals receiving inpatient psychiatric treatment, yet a comprehensive map of quality inpatient care does not exist. AIMS: To isolate and describe quality elements of inpatient psychiatric treatment. METHOD: A survey queried psychiatric inpatient nursing leaders on what they considered to be critical elements of quality. The survey was emailed to 40 American Psychiatric Nurses Association members, and 39 individuals responded. In the survey, participants were asked to comment on the importance of six dimensions of quality as well as quality indicators used on their units. RESULTS: Data from this survey indicate how thought leaders conceptualized quality of inpatient care. A unifying philosophy of care was endorsed as a quality element as was structure that affords staff available time on the unit-engaging with patients. While staffing levels were viewed as important, the respondents commented on the nuances between staffing and quality. Participants endorsed the importance of involving individuals in their treatment planning as well as tapping into patients\u27 perspectives on the treatment experience. CONCLUSION: The participants\u27 responses compliment the quality literature and reinforce the need to develop a comprehensive map of quality elements. These elements interact in complex way, for instance, staffing, engagement, and teamwork is tied to the organizational structure and philosophy of care, which in turn facilitates consumer involvement in care. Thus, gauging the impact of quality on outcomes will demand consideration of the interaction of factors not just the linear relationship of one element to an outcome

Cost-effectiveness plane of base case and sensitivity analyses.

Cost-effectiveness plane of base case and sensitivity analyses.</p

Effectiveness, costs and cost-effectiveness results.

Effectiveness, costs and cost-effectiveness results.</p

Effectiveness of the LiveLighter® campaign on the Western Australian population aged 18 years and over.

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Aggregated costs for the different components of the LiveLighter® campaign.

Aggregated costs for the different components of the LiveLighter® campaign.</p

Meta-analysis methods and forest plots.

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Survey questions for the LiveLighter® campaign.

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