Showing papers on "Health care published in 2007"

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary.

Abstract: Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials. In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD. Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.

Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report

Abstract: To revise 1998 recommendations on childhood obesity, an Expert Committee, comprised of representatives from 15 professional organizations, appointed experienced scientists and clinicians to 3 writing groups to review the literature and recommend approaches to prevention, assessment, and treatment. Because effective strategies remain poorly defined, the writing groups used both available evidence and expert opinion to develop the recommendations. Primary care providers should universally assess children for obesity risk to improve early identification of elevated BMI, medical risks, and unhealthy eating and physical activity habits. Providers can provide obesity prevention messages for most children and suggest weight control interventions for those with excess weight. The writing groups also recommend changing office systems so that they support efforts to address the problem. BMI should be calculated and plotted at least annually, and the classification should be integrated with other information such as growth pattern, familial obesity, and medical risks to assess the child’s obesity risk. For prevention, the recommendations include both specific eating and physical activity behaviors, which are likely to promote maintenance of healthy weight, but also the use of patient-centered counseling techniques such as motivational interviewing, which helps families identify their own motivation for making change. For assessment, the recommendations include methods to screen for current medical conditions and for future risks, and methods to assess diet and physical activity behaviors. For treatment, the recommendations propose 4 stages of obesity care; the first is brief counseling that can be delivered in a health care office, and subsequent stages require more time and resources. The appropriateness of higher stages is influenced by a patient’s age and degree of excess weight. These recommendations recognize the importance of social and environmental change to reduce the obesity epidemic but also identify ways healthcare providers and health care systems can be part of broader efforts.

Promoting and protecting mental health as flourishing: A complementary strategy for improving national mental health.

Abstract: This article summarizes the conception and diagnosis of the mental health continuum, the findings supporting the two continua model of mental health and illness, and the benefits of flourishing to individuals and society. Completely mentally healthy adults--individuals free of a 12-month mental disorder and flourishing--reported the fewest missed days of work, the fewest half-day or greater work cutbacks, the healthiest psychosocial functioning (i.e., low helplessness, clear goals in life, high resilience, and high intimacy), the lowest risk of cardiovascular disease, the lowest number of chronic physical diseases with age, the fewest health limitations of activities of daily living, and lower health care utilization. However, the prevalence of flourishing is barely 20% in the adult population, indicating the need for a national program on mental health promotion to complement ongoing efforts to prevent and treat mental illness. Findings reveal a Black advantage in mental health as flourishing and no gender disparity in flourishing among Whites.

2007 Guidelines for the management of arterial hypertension

Abstract: For several years the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) decided not to produce their own guidelines on the diagnosis and treatment of hypertension but to endorse the guidelines on hypertension issued by the World Health Organization (WHO) and International Society of Hypertension (ISH)1,2 with some adaptation to reflect the situation in Europe. However, in 2003 the decision was taken to publish ESH/ESC specific guidelines3 based on the fact that, because the WHO/ISH Guidelines address countries widely varying in the extent of their health care and availability of economic resource, they contain diagnostic and therapeutic recommendations that may be not totally appropriate for European countries. In Europe care provisions may often allow a more in-depth diagnostic assessment of cardiovascular risk and organ damage of hypertensive individuals as well as a wider choice of antihypertensive treatment. The 2003 ESH/ESC Guidelines3 were well received by the clinical world and have been the most widely quoted paper in the medical literature in the last two years.4 However, since 2003 considerable additional evidence on important issues related to diagnostic and treatment approaches to hypertension has become available and therefore updating of the previous guidelines has been found advisable. In preparing the new guidelines the Committee established by the ESH and ESC has agreed to adhere to the principles informing the 2003 Guidelines, namely 1) to try to offer the best available and most balanced recommendation to all health care providers involved in the management of hypertension, 2) to address this aim again by an extensive and critical review of the data accompanied by a series of boxes where specific recommendations are given, as well as by a concise set of practice recommendations to be published soon thereafter as already done in 2003; …

Preterm Birth: Causes, Consequences, and Prevention

Abstract: The increasing prevalence of preterm birth in the United States is a complex public health problem that requires multifaceted solutions. Preterm birth is a cluster of problems with a set of overlapping factors of influence. Its causes may include individual-level behavioral and psychosocial factors, sociodemographic and neighborhood characteristics, environmental exposure, medical conditions, infertility treatments, and biological factors. Many of these factors co-occur, particularly in those who are socioeconomically disadvantaged or who are members of racial and ethnic minority groups. While advances in perinatal and neonatal care have improved survival for preterm infants, those infants who do survive have a greater risk than infants born at term for developmental disabilities, health problems, and poor growth. The birth of a preterm infant can also bring considerable emotional and economic costs to families and have implications for public-sector services, such as health insurance, educational, and other social support systems. Preterm Birth assesses the problem with respect to both its causes and outcomes. This book addresses the need for research involving clinical, basic, behavioral, and social science disciplines. By defining and addressing the health and economic consequences of premature birth, this book will be of particular interest to health care professionals, public health officials, policy makers, professional associations and clinical, basic, behavioral, and social science researchers.

The international classification for functioning, disability and health. A challenge and a need for rheumatology.

Abstract: The rheumatologic community is in a leading position for the development of International Classification of Functioning, Disability and Health (ICF) Core Sets and the research into the validity and application of the ICF We can be proud of this achievement, but not all of us are aware of this new development What is the ICF? Rheumatologic conditions have major impact on patients Apart from symptoms such as pain, stiffness, and fatigue, patients are limited in activities and restricted in participation in society [2] When unable to continue paid work, for example, there are important consequences for the patients, their families, but also for society A major goal of the management of rheumatic diseases is to maintain or restore functioning This contributes to the well-being of the patients, their families, and other caregivers It is clear that maintaining function requires more than control of disease activity By using the ICF, which was developed by the World Health Organization (WHO), we can obtain information on all three areas that are important for global functioning: body functions and structures, activities (actions by an individual), and participation (involvement in life situations) [3] The ICF is one of the three reference classification systems that were proposed and developed by the WHO and belong to the Family of International Classifications The main aim of the classification systems is to improve integration of health information The International Classification of Diagnosis (ICD) is well known and widely applied [4] The ICF was developed from the older International Classification of Impairments, Disabilities, and Handicaps (ICIDH) and accepted in 2001 [3] It is increasingly recognized as an important classification in clinical medicine, outcome research, and healthcare organization The International Classification of Health Interventions (ICHI) is proposed as the newest member of the family, and its development has just started [1] The WHO aims to implement effectively the ICF worldwide and formulated strategic directions in which the three following are the most relevant: (1) The ICF has to become the framework to classify function, (2) easy-to-use ICF linked instruments should be developed to assess functional outcome as well as effectiveness of interventions, and (3) the level and quality of implementation of the ICF should be improved to increase quality and comparability Clin Rheumatol (2007) 26:1803–1808 DOI 101007/s10067-007-0623-0

Using Evidence: How research can inform public services

Abstract: There is widespread commitment across public service agencies in the UK and elsewhere to ensuring that the best available evidence is used to improve public services. The challenge is not only making research evidence accessible and available, but also getting it used. This book provides a timely and novel contribution to understanding and enhancing evidence use. It builds on and complements the popular and best-selling What Works?: Evidence-Based Policy and Practice in Public Services by drawing together current knowledge from the education, health care, social care, and criminal justice fields.

Analyzing health equity using household survey data : a guide to techniques and their implementation

Abstract: This book shows how to implement a variety of analytic tools that allow health equity - along different dimensions and in different spheres - to be quantified. Questions that the techniques can help provide answers for include the following: Have gaps in health outcomes between the poor and the better-off grown in specific countries or in the developing world as a whole? Are they larger in one country than in another? Are health sector subsidies more equally distributed in some countries than in others? Is health care utilization equitably distributed in the sense that people in equal need receive similar amounts of health care irrespective of their income? Are health care payments more progressive in one health care financing system than in another? What are catastrophic payments? How can they be measured? How far do health care payments impoverish households? This volume has a simple aim: to provide researchers and analysts with a step-by-step practical guide to the measurement of a variety of aspects of health equity. Each chapter includes worked examples and computer code. The authors hope that these guides, and the easy-to-implement computer routines contained in them, will stimulate yet more analysis in the field of health equity, especially in developing countries. They hope this, in turn, will lead to more comprehensive monitoring of trends in health equity, a better understanding of the causes of these inequities, more extensive evaluation of the impacts of development programs on health equity, and more effective policies and programs to reduce inequities in the health sector.

Designing and evaluating complex interventions to improve health care

Abstract: Determining the effectiveness of complex interventions can be difficult and time consuming. Neil C Campbell and colleagues explain the importance of ground work in getting usable results

Do professional interpreters improve clinical care for patients with limited english proficiency? A systematic review of the literature

Abstract: According to the 2000 Census, 47 million people in the United States speak a language other than English at home (Shin and Bruno 2003). Half of these individuals report that they speak English less than “very well.” These individuals are considered to have limited English proficiency (LEP). That is, they are not able to speak, read, write, or understand the English language at a level that permits them to interact effectively with health care providers (OCR 2002). This language barrier puts the health of many LEP individuals, and that of their communities at risk by affecting their ability to access care and communicate with their providers. It is well established that language barriers contribute to health disparities for LEP patients (Jacobs et al. 2003). These patients have less access to a usual source of care, and lower rates of physician visits and preventive services (Fox and Stein 1991; Kirkman-Liff and Mondragon 1991; Woloshin et al. 1997; Fiscella et al. 2002). Even when they do have access to care, LEP patients often have poorer adherence to treatment and follow-up for chronic illnesses, decreased comprehension of their diagnoses and treatment after emergency department (ED) visits, decreased satisfaction with care, and increased medication complications. (Manson 1988; Crane 1997; Carasquillo et al. 1999; Gandhi et al. 2000) In contrast, language concordance between patients and physicians increases patient satisfaction, patient-reported health status, and adherence with medication and follow-up visits (Manson 1988; Perez-Stable, Napoles-Springer, and Miramontes 1997; Freeman et al. 2002). Given that over 100 languages are commonly spoken in the United States, (Shin and Bruno 2003) it is often not possible to provide language concordant health care. In one study of the use of medical interpreters in urban primary care practices, physicians reported encountering 20 different languages (Karliner, Perez-Stable, and Gildengorin 2004). Although some LEP patients are fortunate enough to be seen in settings where physician and office staff speak their primary language, this language concordance can readily disappear once these patients present for laboratory testing, emergency care, or are admitted to the hospital. Therefore, the majority of providers must use other means to communicate with their LEP patients and, if they receive federal financial assistance, are required to do so by Title VI of the Civil Rights Act of 1964 (OCR 2002). Most often this means is a third person, an interpreter, who can range from a highly trained professional medical interpreter to any available bilingual person (NCIHC 2001). In their review and analysis of health plans and language assistance programs, (Brach, Fraser, and Paez 2005) recommend the use of professional interpreters to augment the use of bilingual clinicians and staff in order to improve the quality of care delivered and to decrease health disparities. A recent general review of the literature concludes that the quality of medical care is improved by either use of professional interpreters or via direct provision of care by bilingual health care providers (Flores 2005). These reviews are broad and inclusive; however, many of the studies from which they draw their conclusions combined the effects of different types of interpreters (ad hoc, trained, untrained) as well as that of language concordant clinicians without systematically distinguishing among them. Thus, we are still left with the question of the specific effect of professional interpreters on clinical care, and how their effect compares with that of ad hoc interpreters. Building on these previous reviews, we conducted a focused systematic review of the medical literature to better understand whether use of professional medical interpreters is associated with improved clinical care for LEP patients in the areas of communication errors and patient comprehension, utilization, clinical outcomes, and satisfaction.

Motivational Interviewing in Health Care: Helping Patients Change Behavior

Abstract: Behavior change is a critical part of effective health care. The final decision to become healthier, however, is that of the patient and not the practitioner. Anyone who has treated patients knows ...

Analyzing Health Equity Using Household Survey Data: A Guide to Techniques and their Implementation

Abstract: This book shows how to implement a variety of analytic tools that allow health equity - along different dimensions and in different spheres - to be quantified. Questions that the techniques can help provide answers for include the following: Have gaps in health outcomes between the poor and the better-off grown in specific countries or in the developing world as a whole? Are they larger in one country than in another? Are health sector subsidies more equally distributed in some countries than in others? Is health care utilization equitably distributed in the sense that people in equal need receive similar amounts of health care irrespective of their income? Are health care payments more progressive in one health care financing system than in another? What are catastrophic payments? How can they be measured? How far do health care payments impoverish households? This volume has a simple aim: to provide researchers and analysts with a step-by-step practical guide to the measurement of a variety of aspects of health equity. Each chapter includes worked examples and computer code. The authors hope that these guides, and the easy-to-implement computer routines contained in them, will stimulate yet more analysis in the field of health equity, especially in developing countries. They hope this, in turn, will lead to more comprehensive monitoring of trends in health equity, a better understanding of the causes of these inequities, more extensive evaluation of the impacts of development programs on health equity, and more effective policies and programs to reduce inequities in the health sector.

Assessment of Child and Adolescent Overweight and Obesity

Abstract: Accurate appropriate assessment of overweight and obesity in children and adolescents is a critical aspect of contemporary medical care. However, physicians and other health care professionals may find this a somewhat thorny field to enter. The BMI has become the standard as a reliable indicator of overweight and obesity. The BMI is incomplete, however, without consideration of the complex behavioral factors that influence obesity.Because of limited time and resources, clinicians need to have quick, evidence-based interventions that can help patients and their families recognize the importance of reducing overweight and obesity and take action. In an era of fast food, computers, and DVDs, it is not easy to persuade patients to modify their diets and to become more physically active. Because research concerning effective assessment of childhood obesity contains many gaps, this report is intended to provide a comprehensive approach to assessment and to present the evidence available to support key aspects of assessment. The discussion and recommendations are based on 300 studies published since 1995, which examined an array of assessment tools. With this information, clinicians should find themselves better equipped to face the challenges of assessing childhood overweight and obesity accurately.

Bringing the War Back Home: Mental Health Disorders Among 103 788 US Veterans Returning From Iraq and Afghanistan Seen at Department of Veterans Affairs Facilities

Abstract: Background Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) have endured high combat stress and are eligible for 2 years of free military service–related health care through the Department of Veterans Affairs (VA) health care system, yet little is known about the burden and clinical circumstances of mental health diagnoses among OEF/OIF veterans seen at VA facilities. Methods US veterans separated from OEF/OIF military service and first seen at VA health care facilities between September 30, 2001 (US invasion of Afghanistan), and September 30, 2005, were included. Mental health diagnoses and psychosocial problems were assessed usingInternational Classification of Diseases, Ninth Revision, Clinical Modificationcodes. The prevalence and clinical circumstances of and subgroups at greatest risk for mental health disorders are described herein. Results Of 103 788 OEF/OIF veterans seen at VA health care facilities, 25 658 (25%) received mental health diagnosis(es); 56% of whom had 2 or more distinct mental health diagnoses. Overall, 32 010 (31%) received mental health and/or psychosocial diagnoses. Mental health diagnoses were detected soon after the first VA clinic visit (median of 13 days), and most initial mental health diagnoses (60%) were made in nonmental health clinics, mostly primary care settings. The youngest group of OEF/OIF veterans (age, 18-24 years) were at greatest risk for receiving mental health or posttraumatic stress disorder diagnoses compared with veterans 40 years or older. Conclusions Co-occurring mental health diagnoses and psychosocial problems were detected early and in primary care medical settings in a substantial proportion of OEF/OIF veterans seen at VA facilities. Targeted early detection and intervention beginning in primary care settings are needed to prevent chronic mental illness and disability.

The causal pathways linking health literacy to health outcomes.

Abstract: Objective To provide an evidence-based review of plausible causal pathways that could best explain well-established associations between limited health literacy and health outcomes. Methods Through analysis of current findings in medical and public health literature on health literacy we derived a conceptual causal model. Results Health literacy should be viewed as both a patient and a system phenomenon. Three distinct points along a continuum of health care are suggested to be influenced by health literacy: (1) access and utilization of health care, (2) patient-provider relationship, and (3) self-care. Conclusions The conceptual model organizes what has been learned to date and underscores promising areas of future inquiry and intervention.

Help-seeking and access to mental health care in a university student population.

Abstract: Background: University students represent an important population in which to study access to mental health care. Understanding their unmet needs will enhance efforts to prevent and treat mental disorders during a pivotal period in life. Objective: To quantify mental health service use and estimate how various factors are associated with help-seeking and access in a university student population. Design: A Web-based survey was administered to a random sample of 2785 students attending a large, public university with a demographic profile similar to the national student population. Nonresponse bias was accounted for using administrative data and a nonrespondent survey. Measures: Mental health was measured using the Patient Health Questionnaire screens for depressive and anxiety disorders. Mental health service utilization was measured as having received psychotropic medication or psychotherapy in the past year. Results: Of students with positive screens for depression or anxiety, the proportion who did not receive any services ranged from 37% to 84%, depending on the disorder. Predictors of not receiving services included a lack of perceived need, being unaware of services or insurance coverage, skepticism about treatment effectiveness, low socioeconomic background, and being Asian or Pacific Islander. Conclusions: Even in an environment with universal access to free short-term psychotherapy and basic health services, most students with apparent mental disorders did not receive treatment. Initiatives to improve access to mental health care for students have the potential to produce substantial benefits in terms of mental health and related outcomes.

Public Reporting and Pay for Performance in Hospital Quality Improvement

Abstract: BACKGROUND Public reporting and pay for performance are intended to accelerate improvements in hospital care, yet little is known about the benefits of these methods of providing incentives for improving care. METHODS We measured changes in adherence to 10 individual and 4 composite measures of quality over a period of 2 years at 613 hospitals that voluntarily reported information about the quality of care through a national public-reporting initiative, including 207 facilities that simultaneously participated in a pay-for-performance demonstration project funded by the Centers for Medicare and Medicaid Services; we then compared the pay-for-performance hospitals with the 406 hospitals with public reporting only (control hospitals). We used multivariable modeling to estimate the improvement attributable to financial incentives after adjusting for baseline performance and other hospital characteristics. RESULTS As compared with the control group, pay-for-performance hospitals showed greater improvement in all composite measures of quality, including measures of care for heart failure, acute myocardial infarction, and pneumonia and a composite of 10 measures. Baseline performance was inversely associated with improvement; in pay-for-performance hospitals, the improvement in the composite of all 10 measures was 16.1% for hospitals in the lowest quintile of baseline performance and 1.9% for those in the highest quintile (P<0.001). After adjustments were made for differences in baseline performance and other hospital characteristics, pay for performance was associated with improvements ranging from 2.6 to 4.1% over the 2-year period. CONCLUSIONS Hospitals engaged in both public reporting and pay for performance achieved modestly greater improvements in quality than did hospitals engaged only in public reporting. Additional research is required to determine whether different incentives would stimulate more improvement and whether the benefits of these programs outweigh their costs.

Planning and studying improvement in patient care : The use of theoretical perspectives

Abstract: A consistent finding in articles on quality improvement in health care is that change is difficult to achieve. According to the research literature, the majority of interventions are targeted at health care professionals. But success in achieving change may be influenced by factors other than those relating to individual professionals, and theories may help explain whether change is possible. This article argues for a more systematic use of theories in planning and evaluating quality-improvement interventions in clinical practice. It demonstrates how different theories can be used to generate testable hypotheses regarding factors that influence the implementation of change, and it shows how different theoretical assumptions lead to different quality-improvement strategies.

Protecting households from catastrophic health spending.

Abstract: Many countries rely heavily on patients’ out-of-pocket payments to providers to finance their health care systems. This prevents some people from seeking care and results in financial catastrophe a...

Goodness of fit: social work education and practice in health care.

Abstract: This study addresses the fit between social work education and practice in health care. A random sample of NASW members identifying with health care (N = 179) responded to a mail survey about the utility of core knowledge and roles that we had identified by reviewing seven commonly used health care social work texts. Quantitative data revealed knowledge and roles most frequently used in health care settings as well as differences in roles used dependent upon department name; and different professionals supervising social workers. Qualitative data from four open-ended questions provided suggestions for what knowledge and skills should be taught in social work programs, the best forums/methods for teaching this content, and topics for continuing education. Findings are discussed in relation to six key areas of the peer-reviewed literature: vulnerable populations/diversity, ethical dilemmas, interdisciplinary collaboration, mental health, managed care/accountability, and advocacy. Implications for social work practice, education, and research are discussed.

Prescription drug cost sharing: associations with medication and medical utilization and spending and health.

Abstract: ContextPrescription drugs are instrumental to managing and preventing chronic disease. Recent changes in US prescription drug cost sharing could affect access to them.ObjectiveTo synthesize published evidence on the associations among cost-sharing features of prescription drug benefits and use of prescription drugs, use of nonpharmaceutical services, and health outcomes.Data SourcesWe searched PubMed for studies published in English between 1985 and 2006.Study Selection and Data ExtractionAmong 923 articles found in the search, we identified 132 articles examining the associations between prescription drug plan cost-containment measures, including co-payments, tiering, or coinsurance (n = 65), pharmacy benefit caps or monthly prescription limits (n = 11), formulary restrictions (n = 41), and reference pricing (n = 16), and salient outcomes, including pharmacy utilization and spending, medical care utilization and spending, and health outcomes.ResultsIncreased cost sharing is associated with lower rates of drug treatment, worse adherence among existing users, and more frequent discontinuation of therapy. For each 10% increase in cost sharing, prescription drug spending decreases by 2% to 6%, depending on class of drug and condition of the patient. The reduction in use associated with a benefit cap, which limits either the coverage amount or the number of covered prescriptions, is consistent with other cost-sharing features. For some chronic conditions, higher cost sharing is associated with increased use of medical services, at least for patients with congestive heart failure, lipid disorders, diabetes, and schizophrenia. While low-income groups may be more sensitive to increased cost sharing, there is little evidence to support this contention.ConclusionsPharmacy benefit design represents an important public health tool for improving patient treatment and adherence. While increased cost sharing is highly correlated with reductions in pharmacy use, the long-term consequences of benefit changes on health are still uncertain.

Public health. Implementation science.

Abstract: W e face a formidable gap between innovations in health (including vaccines, drugs, and strategies for care) and their delivery to communities in the developing world. As a result, nearly 14,000 people in sub-Saharan Africa and South Asia die daily from HIV, malaria, and diarrheal disease (1), even though scientific advances have enabled prevention, treatment, and, in some cases, elimination of these diseases in developed countries. Many evidence-based innovations fail to produce results when transferred to communities in the global south, largely because their implementation is untested, unsuitable, or incomplete. For example, rigorous studies have shown that appropriate use of insecticide treated bed nets can prevent malaria (2), yet, in 2002, fewer than 10% of children in 28 sub-Saharan African countries regularly slept with this protection (3). Newer studies have shown that malaria incidence is decreased by distribution of free nets, but further research is needed to promote cost-effective, sustained access—particularly for the poor living in rural areas (4). The same is true of strategies to prevent mother-to-child transmission of HIV. Although interventions like prophylactic anti-retroviral therapy and replacement feeding have worked well in hospitals and clinics, increasing coverage in rural areas (where women have limited access to clean water and formal health care) may require testing of novel approaches, such as self-administration of drugs (5, 6). Similarly, the scale-up of male circumcision, which has been shown to protect against HIV transmission in recent clinical trials (7), will require development of safe, culturally acceptable, and accessible methods for surgery and care (8). Why is effective implementation, particularly in resource-poor countries, such an intractable problem? The reasons are complex. First, scientists have been slow to view implementation as a dynamic, adaptive, multiscale phenomenon that can be addressed through a research agenda. Although randomized, controlled experiments are the gold standard for testing safety and efficacy of pharmaceuticals , health delivery schemes are less likely to be subject to rigorous scientific analysis. Second, people living in poverty face a bewildering constellation of social constraints and health threats that make prevention and treatment more difficult. They often have limited knowledge of preventive health practices and insufficient or sporadic access to quality care. Their health systems are underfinanced, underregulated, and crippled by health-worker shortages. Even for those with access to care, health is routinely undermined by heavy pathogen loads, environmental exposures, inadequate sanitation infrastructure, and socioeconomic barriers to behavior change. Faced with such challenges, it …