Here, I venture into the sociology of the professions to discuss the impact of empowerment evaluation on the autonomy of its practitioners. I do so because I found the process of conducting an empowerment evaluation to be challenging during the first four years of a Substances and Mental Health Services Administration (SAMHSA) system-of-care (SOC) mental health services transformation for youth with serious emotional disturbance (SED). My goal is to offer readers some suggestions about how to avoid these challenges in the future.

How do youth from various community groups designated as having a serious emotional disturbance (SED) recover over time? We conducted an evaluation of a Substance Abuse and Mental Health Services Administration System of Care grant initiative for Monroe County, New York, to answer this and other questions. We looked at outcome differences over time using the Behavioral and Emotional Ratings Scale’s (2nd ed.) overall strength scores among youth living in four geographical places at the start of services: high-income urban, low-income urban, suburban, and rural. Minorities (be they nonwhite or white) within each group, except suburban, had the higher probability of being designated as having SED. We found recovery disparities among white urban youth and their nonurban counterparts, and among nonwhite suburban and high-income urban youth and their low-income urban and rural counterparts. Applied implications include the following: (a) Continue the restructuring of mental health and juvenile justice agencies to become more culturally competent, (b) create a social marketing campaign to address the stigma surrounding mental illness, (c) build coalitions to publicize risk factors to mental health and their prevention, (d) restructure schools away from the prevailing eurocentric model of education, and (e) create a labor hour exchange for the repair and upgrade of housing and other infrastructure.

To what extent might race and where one lives at service start in Monroe County, New York, influence three dimensions of caregiver strain among those caring for a youth designated as having serious emotional disturbance? We used the Caregiver Strain Questionnaire to measure our outcomes: subjective internalizing strain—negative feelings of guilt and worry associated with having a child with behavioral and emotional problems; subjective externalizing strain—negative feelings about the child such as anger or embarrassment; and objective strain—interruption of personal time, lost work time, and/or financial strain in four geographical areas (place of residence) defined by ZIP code. These places included Low Income Urban (median ZIP code household income less than $39,000), High Income Urban (median ZIP code household income greater than or equal to $39,000), Suburban, and Rural. We found that place at service start and time predicted caregiver strain levels (though time was the only predictor for externalizing strain), controlling for several factors. Race had no detectable influence. Supports can be individualized to a greater extent to address specific factors influencing the type of strain experienced by a caregiver. Providers might begin by identifying caregiver strain by type and intensity as well as identifying the specific circumstances leading to feelings and concerns associated with each type of caregiver strain.

Few studies offer guidance on best practice for social workers in assessment and recommendation of treatment services for specialty mental health services within a system of care (SOC). This study examined factors associated with service assignment among a population of children and youth (N= 1,270) entering a federally funded system of care program referred to specialty mental health services. Logistic regression was used to examine the likelihood of children and youth determined in need of varying levels of care coordination services based on child factors and referral source. Older youth, youth with internalizing problems, and those referred from mental health compared to juvenile justice and schools were significantly more likely determined in need of more intensive care coordination services. Race was not significantly associated with level of care determination. Findings suggest that differences exist in level of care determination for children entering system of care referred by the juvenile justice system and related services and schools. Social workers and providers need to be aware of these differences in order to properly screen children for internalizing problems when referred by sources other than mental health.

Organizations conduct external evaluations for several reasons. They might want an independent assessment showing that their program is effective to garner community support, favorably influence public policy related to their mission, support their future bids for financial support, provide critical information for continuous quality assessment (although much of the latter is conducted internally by the organizations themselves), or because an external evaluation is required under the terms of a grant they received. The author focuses on the latter and argues that the quality of these evaluations is dependent on the continued involvement of funding agencies after the grant is awarded. He suggests four things that funders can do to address this challenge.

Background More than 30% of the pregnancies in women aged 35 and over are unintended. This paper compares perceptions about contraceptive methods and use among women with and without an unintended pregnancy after turning age 35. Methods Semi-structured, in-depth interviews were conducted with 17 women. They were all 35 to 49 years old, regularly menstruating, sexually active, not sterilized, not desiring a pregnancy in the near future, and at least 3 months postpartum. We purposely sampled for women who had had at least one unintended pregnancy after age 35 (n = 9) and women who did not (n = 8). We assessed partnership, views of pregnancy and motherhood, desired lifestyle, perceived advantages and disadvantages of using and obtaining currently available well-known reversible contraceptives in the U.S. ''We also assessed contraceptive methods used at any time during their reproductive years, including current method use and, if appropriate, circumstances surrounding an unintended pregnancy after age 35.'' Each interview was taped and transcribed verbatim. Data were analyzed using Grounded Theory. Analysis focused on partnership, views of pregnancy, motherhood, desired lifestyle and perceived advantages and disadvantages of various reversible contraceptive methods. Results The women without an unintended pregnancy after age 35 were more likely to (1) use contraceptive methods that helped treat a medical condition, (2) consider pregnancy as dangerous, or (3) express concerns about the responsibilities of motherhood. The women who experienced an unintended pregnancy after age 35 were more likely to (1) report unstable partnerships, (2) perceive themselves at lower risk of pregnancy, or (3) report past experiences with unwanted contraceptive side effects. There was a greater likelihood a woman would choose a contraceptive method if it was perceived as easy to use, accessible, affordable and had minimal side effects. Conclusions Women's perspective on contraceptive use after age 35 varies. Public health messages and health providers' care can help women in this age group by reviewing their fertility risks, as well as all contraceptive methods and their associated side effects. The impact of such interventions on unintended pregnancy rates in this age group should be tested in other areas of evidence-based medicine.

Background Determining medical abortion outcome commonly includes a costly evaluation such as ultrasonography or serial serum hCG testing. Urine pregnancy testing may represent a less costly alternative. Methods This prospective diagnostic test evaluation study was part of a multisite randomized trial of 1080 women undergoing medical abortion up to 63 days' gestation who returned 1 and 2 weeks after receiving mifepristone. Low-sensitivity (LS) and high-sensitivity (HS) urine pregnancy tests were performed at each visit, and the results were compared to ultrasonography. Sensitivity, specificity, predictive values and likelihood ratios of each urine test were determined. Results In the first week following abortion, 14.8% of the LS tests and 7.9% of the HS tests correctly predicted outcome. None of the LS tests and only 0.2% of the HS tests were falsely negative; however, 85.2% of the LS tests and 91.8% of the HS tests were falsely positive. In the second week following abortion, 39.1% of the LS tests and 33.8% of the HS tests correctly predicted the medical abortion outcome. Only 0.2% of the LS tests and 0.3% of the HS were falsely negative; however, 60.8% of the LS tests and 65.8% of the HS tests were falsely positive. Conclusions Both LS and HS urine pregnancy assays reliably assess clinical outcomes of medical abortions in cases of negative test results. However, the clinical utility of urine assay testing is limited because of the high rate of false-positive results.

Objective: To determine if use of intravaginal polycarbophil gel (Replens (TM)) for 1 month will: (1) lower vaginal pH; (2) improve signs of bacterial vaginosis (BV).Study design: Seventeen women with BV self-administered polycarbophil gel every third day for 4 weeks in an open-label, prospective pilot study. Primary outcome measures included vaginal pH, presence of amines and Nugent scores.Results: At week 4, there was improvement in Nugent-scores, vaginal odor and clue cell count (p < 0.05). Eleven women converted from amine positive to negative (73 +/- 20%). There was no significant change in vaginal pH.Conclusions: Polycarbophil gel is associated with improved signs of BV, although not vaginal pH. (C) 2006 Elsevier Ireland Ltd. All rights reserved.

Background: New indications for misoprostol include medical abortion, cervical softening, induction of labor and treatment of postpartum hemorrhage. Various routes of misoprostol administration under study include oral, vaginal, buccal, sublingual and rectal.Materials and Methods: This was an open-label, randomized, cross-over study of the pharmacokinetic differences of buccal vs. sublingual misoprostol 800 mug in 10 healthy women.Results: Of the 10 women enrolled, 2 withdrew after experiencing excessive cramping from the sublingual route of misoprostol. The mean misoprostol plasma concentration-time curves at 4 h [area under the curve (AUC)(0-4))] and the maximum concentration (C-max) showed that levels were significantly higher for sublingual administration than the buccal route. Buccal misoprostol administration resulted in fewer symptoms and was found to be more acceptable.Conclusions: Sublingual administration of misoprostol had a higher AUC and C-max compared with buccal administration. The pharmacokinetics may help to determine the best application of misoprostol depending on the indication. (C) 2005 Elsevier Inc. All rights reserved.

Introduction: We performed this trial to ascertain the accuracy of low-sensitivity (LS) and high-sensitivity (HS) urine pregnancy tests in determining gestational sac expulsion following treatment with mifepristone and misoprostol for medical abortion.

OBJECTIVE:To examine attitudes of women presenting for elective abortions.METHOD:Women presenting for elective abortion induced with medication at an urban free-standing abortion clinic were given semistructured interviews about their attitudes to abortion.RESULTS:Of the 60 women interviewed, 26 voiced antichoice attitudes. These interviews were transcribed and analyzed for themes. The women with antichoice attitudes were similar to the women with prochoice attitudes in age, education, and religion but were less likely to be white (61.8% of prochoice women identified themselves as white, compared with 30.8% of antichoice women, P = 0.02). The antichoice women felt most strongly that other women should not be allowed to have an abortion if they gave as their reason, "want no more children," "not married," or "cannot afford." The most common themes were that one needed "enough" reasons to have an abortion and that women should take better precautions to prevent conception.CONCLUSION:It is important for abortion clinic staff to realize that many women coming to an abortion clinic have antichoice views. These views may affect a woman's ability to recover emotionally after the procedure and will therefore have implications for the kind of supportive care women need both before and after the abortion.

Objective: Mifepristone-misoprostol medical abortion has been approved in the United States since 2000. U.S. providers have preferred to use vaginal misoprostol because of evidence that such a regimen is more effective in later gestations. Buccal administration of misoprostol may be equally effective and more acceptable to some women.Methods: This open-label, randomized trial was conducted at two sites in Rochester, NY, and involved healthy women with pregnancies through 56 days since the last menstrual period (LMP) as indicated by sonogram. Women received mifepristone 200 mg orally and were randomized to use 800 mu g of misoprostol either buccally or vaginally 1 to 2 days later. They returned within 15 days for repeat sonogram. If the woman's pregnancy had not been completely aborted by day 36, a suction abortion was performed. The primary outcome was a complete abortion without surgical intervention.Results: Four hundred forty-two women were enrolled in the study, and complete data were available on 429. The efficacy rate was 95% (205/216) in the buccal group and 93% (199/213) in the vaginal group (chi(2) = 0.43, p = .51). Nausea was the most commonly reported side effect, affecting 70% in the buccal group and 62% in the vaginal group. There were no differences in the satisfaction with the overall procedure between the buccal (92%) and the vaginal groups (95%) (chi(2) = 1.87, p = .17).Conclusion: Buccal administration of misoprostol after low-dose mifepristone for medical abortion appears to be a highly effective and acceptable alternative compared with vaginal administration for medical abortion in pregnancies through 56 days LMP. (c) 2005 Elsevier Inc. All rights reserved.

Of 50 women seeking an abortion in Rochester, New York, between November 1999 and January 2001, 35 went on to complete an in-depth interview from 1 to 6 weeks after their follow-up clinical visit. A higher proportion of women who defined their pregnancy as a baby indicated emotional distress during their in-depth interview compared to those who saw their pregnancy as only having the potential to become a baby. The authors conclude that abortion might be made less difficult through public education about the different views of pregnancy and abortion throughout U.S. history. It might be important for abortion counselors to first ask a woman how she defines her pregnancy. A larger study is warranted.

Objective: To examine the differences in anxiety levels and attitudes towards abortion between women having an early medical abortion and women having a surgical (manual vacuum aspiration) abortion.

In this randomized pilot study, we compared the contraceptive efficacy, safety and side effect profiles of weekly versus planned postcoital regimens of low-dose mifepristone. Forty participants were randomized to receive mifepristone 10 mg weekly or planned postcoitally (to be used no more frequently than once every 5 days), for 12 consecutive months. Participants were evaluated monthly to determine pregnancy, ovulation status and acceptability of physical side effects. We ended this pilot study prematurely due to low efficacy and predetermined stopping rules. Three pregnancies during 56 woman-months occurred in the weekly group and three pregnancies during 68 woman-months occurred in the planned postcoital group. Almost half of the participants ovulated monthly on either regimen. The majority of the participants found the physical side effects of these regimens acceptable. Participants in the planned postcoital group, however, found adhering to the regimen more difficult than those in the weekly group. Mifepristone 10 mg used weekly or planned postcoitally did not adequately prevent pregnancy in our pilot study population. Although the concept of intermittent low-dose mifepristone is appealing, the contraceptive effectiveness was disappointing.

The Ethiopian health care system is under tremendous reform. One of the issues high on the agenda is health care financing. In an effort to protect citizens from catastrophic effects of the clearly high share of out-of-pocket expenditure, the government is currently working to introduce health insurance.This article aims to highlight the components of the Ethiopian health care financing reform and discuss its implications on access to essential medicines.A desk review of government policy documents and proclamations was done. Moreover, a review of the scientific literature was done via PubMed and search of other local journals not indexed in PubMed.Revenue retention by health facilities, systematizing the fee waiver system, standardizing exemption services, outsourcing of nonclinical services, user fee setting and revision, initiation of compulsory health insurance (community-based health insurance and social health insurance), establishment of a private wing in public hospitals, and health facility autonomy were the main components of the health care financing reform in Ethiopia. Although limited, the evidence shows that there is increased health care utilization, access to medicines, and quality of services as a result of the reforms.Encouraging progress has been made in the implementation of health care financing reforms in Ethiopia. However, there is shortage of evidence on the effect of the health care financing reforms on access to essential medicines in the country. Thus, a clear need exists for well-organized research on the issue.

This prospective, open-label, randomized trial of healthy adult women up to 9 weeks pregnant compared mifepristone 200 mg followed 2 days later with misoprostol 400 μg orally versus misoprostol 800 μg vaginally. The study was interrupted after the oral misoprostol group experienced a higher than expected failure rate. This treatment was discontinued and another substituted consisting of oral misoprostol 800 μg divided into two doses two hours apart. Women returned for a follow-up visit from Day 4 to 8. All women with a continuing pregnancy received a repeat dose of misoprostol vaginally and returned before Day 15. The primary outcome measure was a complete medical abortion without surgical intervention at the first visit. Of the 1045 women enrolled, 1011 had complete data: Group 1 (220) used oral misoprostol 400 μg, Group 2 (269) used oral misoprostol 800 μg, and Group 3 (522) used vaginal misoprostol 800 μg. At first follow-up visit, the primary outcome, that is, a complete abortion, was 84% for Group 1, 92% for Group 2, and 96% for Group 3, p < 0.001. After a second dose of vaginal misoprostol in women with on-going pregnancies at their first follow-up visit, the complete abortion rates were 91%, 95%, and 98%, respectively, p < 0.001. There were minimal differences in side effects, onset of bleeding and overall acceptability in the three groups. Mifepristone 200 mg followed by vaginal misoprostol 2 days later was more effective at inducing an abortion up to 9 weeks of pregnancy than the same dose of mifepristone followed by oral misoprostol.

The debate about health care reform has gone on for many years. The debate has generated often innovative ideas for reform that transcend national boundaries. For example, proposals have been made for an extension of health insurance with a framework of social protection; progressive development of funding methods; controls on expenditure; bringing benefits into line with what is actually needed; and the application of technological advances. The book concentrates on health insurance policy innovations in selected countries in Africa, the Americas, Asia, and Europe. In addition this book addresses recent institutional economic findings with regard to application of information technology in health insurance systems. Topics discussed include: new approaches in extending coverage in a health insurance system, confronting resource scarcity: innovative strategies, refining benefits to meet current needs, new institutional and administrative frameworks, and transformation through information technology systems. Many of the innovations presented here have already been integrated into existing reforms and the authors refer to concrete developments in individual countries and regions. This book presents those important innovations to social health insurance systems in industrialized and developing countries that have been brought forward in recent years and, as far as possible, already evaluated. In doing so, the intention is to show developments that are valid for more than one country and could have long term impact on health insurance systems. This book is intended to promote deeper exchanges of experience between differing regions, countries, and health insurance systems. In this way it will stimulate ideas for politicians and practitioners, scientists and other experts.

CONTEXT:Women choose medical over surgical abortion because it is more natural, more private and less painful. Whether their perceptions change during the medical abortion process has not been explored. METHODS:A nonprobabilitysample of 43 participants in a clinical trial of abortion using mifepristone completed two open-ended questionnaires about this method, one before taking mifepristone and the second during their follow-up clinic visit 4-8 days after taking misoprostol. Thirty women participated in in-depth interviews 1-6 weeks following their abortion. Researchers analyzed transcripts to identify common themes. RESULTS:On the first visit to the clinic, women expressed anxiety and uncertainty about the effectiveness of medical abortion, guilt or ambivalence, and a desire to avoid surgery. For most women, emotional distress decreased after their abortion. Control was the overarching theme women expressed regarding the meaning of the procedure: Women stressed the importance of being able to select the type of abortion procedure, to maintain control over their future and to preserve their family's quality of life, given the constraints of time, finances and emotional resources. In in-depth interviews, eight women remained concerned about long-term health effects; 18 said that having an abortion at home was a comfortable experience. CONCLUSIONS:Learning whether women are concerned about personal control may help clinicians identify appropriate candidates for medical abortion. In addition, clinicians could help allay women's anxiety at their first abortion visit by explaining that the uncertainties posed by any medical procedure create similar feelings. Clinicians also should reemphasize at the follow-up visit that there are no long-term health effects related to abortion.