Most current models in health psychology assume that stress adversely affects physical health. We re-examined this assumption by reviewing extensive data from the literature and from six samples of our own, in which we collected measures of personality, health and fitness, stress, and current emotional functioning. Results indicate that self-report health measures reflect a pervasive mood disposition of negative affectivity (NA); self-report stress scales also contain a substantial NA component. However, although NA is correlated with health compliant scales, it is not strongly or consistently related to actual, long-term health status, and thus will act as a general nuisance factor in health research. Because self-report measures of stress and health both contain a significant NA component, correlations between such measures likely overestimate the true association between stress and health. Results demonstrate the importance of including different types of health measures in health psychology research.

Health complaints, stress, and distress: exploring the central role of negative affectivity.

Adjustment to threatening events: A theory of cognitive adaptation.

Background
Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. Little is known, however, about the effectiveness of LHW interventions.

Objectives
To assess the effects of LHW interventions in primary and community health care on maternal and child health and the management of infectious diseases.

Search methods
For the current version of this review we searched The Cochrane Central Register of Controlled Trials (including citations uploaded from the EPOC and the CCRG registers) (The Cochrane Library 2009, Issue 1 Online) (searched 18 February 2009); MEDLINE, Ovid (1950 to February Week 1 2009) (searched 17 February 2009); MEDLINE In-Process & Other Non-Indexed Citations, Ovid (February 13 2009) (searched 17 February 2009); EMBASE, Ovid (1980 to 2009 Week 05) (searched 18 February 2009); AMED, Ovid (1985 to February 2009) (searched 19 February 2009); British Nursing Index and Archive, Ovid (1985 to February 2009) (searched 17 February 2009); CINAHL, Ebsco 1981 to present (searched 07 February 2010); POPLINE (searched 25 February 2009); WHOLIS (searched 16 April 2009); Science Citation Index and Social Sciences Citation Index (ISI Web of Science) (1975 to present) (searched 10 August 2006 and 10 February 2010). We also searched the reference lists of all included papers and relevant reviews, and contacted study authors and researchers in the field for additional papers.

Selection criteria
Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to improve maternal or child health or the management of infectious diseases. A 'lay health worker' was defined as any health worker carrying out functions related to healthcare delivery, trained in some way in the context of the intervention, and having no formal professional or paraprofessional certificate or tertiary education degree. There were no restrictions on care recipients.

Data collection and analysis
Two review authors independently extracted data using a standard form and assessed risk of bias. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the study results were combined and an overall estimate of effect obtained.

Main results
Eighty-two studies met the inclusion criteria. These showed considerable diversity in the targeted health issue and the aims, content, and outcomes of interventions. The majority were conducted in high income countries (n = 55) but many of these focused on low income and minority populations. The diversity of included studies limited meta-analysis to outcomes for four study groups. These analyses found evidence of moderate quality of the effectiveness of LHWs in promoting immunisation childhood uptake (RR 1.22, 95% CI 1.10 to 1.37; P = 0.0004); promoting initiation of breastfeeding (RR = 1.36, 95% CI 1.14 to 1.61; P < 0.00001), any breastfeeding (RR 1.24, 95% CI 1.10 to 1.39; P = 0.0004), and exclusive breastfeeding (RR 2.78, 95% CI 1.74 to 4.44; P <0.0001); and improving pulmonary TB cure rates (RR 1.22 (95% CI 1.13 to 1.31) P <0.0001), when compared to usual care. There was moderate quality evidence that LHW support had little or no effect on TB preventive treatment completion (RR 1.00, 95% CI 0.92 to 1.09; P = 0.99). There was also low quality evidence that LHWs may reduce child morbidity (RR 0.86, 95% CI 0.75 to 0.99; P = 0.03) and child (RR 0.75, 95% CI 0.55 to 1.03; P = 0.07) and neonatal (RR 0.76, 95% CI 0.57 to 1.02; P = 0.07) mortality, and increase the likelihood of seeking care for childhood illness (RR 1.33, 95% CI 0.86 to 2.05; P = 0.20). For other health issues, the evidence is insufficient to draw conclusions regarding effectiveness, or to enable the identification of specific LHW training or intervention strategies likely to be most effective.

Authors' conclusions
LHWs provide promising benefits in promoting immunisation uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared to usual care. For other health issues, evidence is insufficient to draw conclusions about the effects of LHWs.

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Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases.

BACKGROUND
Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. However, little is known about the effectiveness of LHW interventions.


OBJECTIVES
To assess the effects of LHW interventions in primary and community health care on health care behaviours, patients' health and wellbeing, and patients' satisfaction with care.


SEARCH STRATEGY
We searched the Cochrane Effective Practice and Organisation of Care and Consumers and Communication specialised registers (to August 2001); the Cochrane Central Register of Controlled Trials (to August 2001); MEDLINE (1966- August 2001); EMBASE (1966-August 2001); Science Citations (to August 2001); CINAHL (1966-June 2001); Healthstar (1975-2000); AMED (1966-August 2001); the Leeds Health Education Effectiveness Database and the reference lists of articles.


SELECTION CRITERIA
Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to promote health, manage illness or provide support to patients. A 'lay health worker' was defined as any health worker carrying out functions related to health care delivery; trained in some way in the context of the intervention; and having no formal professional or paraprofessional certificated or degreed tertiary education. There were no restrictions on the types of consumers.


DATA COLLECTION AND ANALYSIS
Two reviewers independently extracted data onto a standard form and assessed study quality. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the results of included studies were combined and an estimate of effect obtained.


MAIN RESULTS
Forty three studies met the inclusion criteria, involving more than 210,110 consumers. These showed considerable diversity in the targeted health issue and the aims, content and outcomes of interventions. Most were conducted in high income countries (n=35), but nearly half of these focused on low income and minority populations (n=15). Study diversity limited meta-analysis to outcomes for five subgroups (n=15 studies) (LHW interventions to promote the uptake of breast cancer screening, immunisation and breastfeeding promotion [before two weeks and between two weeks and six months post partum] and to improve diagnosis and treatment for selected infectious diseases). Promising benefits in comparison with usual care were shown for LHW interventions to promote immunisation uptake in children and adults (RR=1.30 [95% CI 1.14, 1.48] p=0.0001) and LHW interventions to improve outcomes for selected infectious diseases (RR=0.74 [95% CI 0.58, 0.93) p=0.01). LHWs also appear promising for breastfeeding promotion. They appear to have a small effect in promoting breast cancer screening uptake when compared with usual care. For the remaining subgroups (n=29 studies), the outcomes were too diverse to allow statistical pooling. We can therefore draw no general conclusions on the effectiveness of these subgroups of interventions.


AUTHORS' CONCLUSIONS
LHWs show promising benefits in promoting immunisation uptake and improving outcomes for acute respiratory infections and malaria, when compared to usual care. For other health issues, evidence is insufficient to justify recommendations for policy and practice. There is also insufficient evidence to assess which LHW training or intervention strategies are likely to be most effective. Further research is needed in these areas.

Lay health workers in primary and community health care : Cochrane systematic review. Commentary

The nature and quality of adolescents' attachments to peers and parents were assessed with the newly developed Inventory of Adolescent Attachments. The relative influence on measures of self-esteem and life satisfaction of relations with peers and with parents was then investigated in a hierarchical regression model. The sample consisted of 213 adolescents ranging from 12 to 19 years of age. Two hypotheses were tested: (1) The quality of perceived attachments both to parents and peers would be related to well-being, and (2) the quality of parental relationships would be a more powerful predictor of well-being than would the quality of peer relationships. Confirming the study's hypotheses, the perceived quality of the adolescents' relationships to both peers and parents, their frequency of utilization of peers, and their degree of negative life change were significantly related to both measures of well-being. The quality of attachment to parents was significantly more powerful than that to peers in predicting well-being. In addition, quality of attachment to parents showed a moderating effect under conditions of high life stress on the measures of self-esteem. The study suggests that it is useful to consider the quality of attachments to significant others as an important variable throughout the life span.

The nature and importance of attachment relationships to parents and peers during adolescence

The study evaluated the psychosocial functioning levels of a group of chronically ill (diabetic, asthmatic, cystic fibrotic, and hearing-impaired) children across a battery of standardized personality instruments. The assessments were performed to provide a rigorous test of the popular hypothesis that chronically ill children are especially vulnerable to psychopathology. In contrast to this stereotype, results across measures demonstrated the normalcy rather than the deviance of these children. Although exceptions were noted, the children's functional strengths and coping abilities noticeably outweighed their weaknesses.

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Chronically ill children. A psychologically and emotionally deviant population

Life stress and the psychological and medical adjustment of chronically ill children.

The present study assessed the personality styles, attitudes, perspectives, and coping strategies of 133 mothers and 93 fathers of diabetic, asthmatic, crystic fibrotic, and hearing-impaired children. Across measures, both the essential positive adjustment levels and special problems of the sample were demonstrated, such that they formed a distinct group whose functioning fell between that reported for either “normalℍ or poorly-adjusted parents. Furthermore, the presence of the ill child served as the primary contributor to these patterns, with types of illness providing a secondary but significant thrust to its exact extent and scope. Mothers consistently reported more problems and more involvement than fathers, which illustrated their differential roles within these particular families as well as their typical modes of response to the stress of the ill child. Without a doubt, the stress was taking its toll on the parents. Even though they still managed to cope, a focus on the parental needs is necessary in the total management program for the physically ill child.

Psychosocial effects on parents of raising a physically handicapped child

Relative effectiveness of behavioral and reflective group counseling with parents of mentally retarded children.

This article describes group parent training procedures for a sample of 42 foster mothers. Half of the foster mothers were trained in behavioral child-rearing skills, and the other half received reflective group counseling for 8 weeks. Comparison of the two modes of training showed that reflectively counseled mothers improved primarily in parent attitudes, whereas behaviorally trained mothers improved primarily in actual use of appropriate behavioral skills, reporting reductions in problematic child behavior and improvements in overall family functioning. The future use of a combination approach is addressed, as are suggestions regarding how to motivate foster parents and improve their attendance rates. Throughout the 1970s the use of parent counseling and training has grown as a means of employing parents as therapists for their children's problem behaviors. Tavormina (1974) discussed two major topics of parent counseling: (a) reflective counseling, which emphasizes parental awareness, understanding, and acceptance of the child's feelings, and (b) behavioral counseling, which emphasizes actual observable behavior and the environmental variables that maintain certain behavior patterns. In a comparison of the relative effectiveness of the two procedures (Tavormina, 1975), both had beneficial effects relative to the notreatment control condition, but the behavioral method resulted in a significantly greater magnitude of improvement across attitude and behavior change dimensions. Tavormina's (1975) study trained biological mothers of retarded children, and the present study represents an extension of that study to foster mothers, who differ from other parents along several dimensions. First, these parents are charged with the duty of managing children who are wards of the state, yet they have consistently been implicated as being neither economically nor therapeutically prepared to manage the children entrusted to their care (Levitt, 1973). Second, foster children as a

Joseph B. Tavormina

Papers

Chronically ill children. A psychologically and emotionally deviant population

Life stress and the psychological and medical adjustment of chronically ill children.

Psychosocial effects on parents of raising a physically handicapped child

Relative effectiveness of behavioral and reflective group counseling with parents of mentally retarded children.

Relative Effectiveness of Behavioral and Reflective Group Training With Foster Mothers