Quality of Care

Objective: Our study explored if patient risk factors for cesarean delivery (CD) are changing over time. Study design: North Carolina birth certificates from 1995 were used to build a logistic regression model to predict the probability of primary CD. The model estimated each patient's probability of primary CD for 4 years of deliveries (397,793). The percentage of the population in each of the 10 CD risk deciles were compared across years. Results: The incidence of primary CD rose from 16.6 to 18.4 (P!.0001). Despite this increase over time, more women were low risk (probability of CD !10%) (43.2% to 46.4%, P! .0001). The cesarean rate even rose for women in the lowest risk group (4.6% to 5.9%, P!.0001). Conclusion: The rate of primary CD is increasing, despite improvements in patient risk profile. The increasing CD rate may result from changes in physician behavior, institutional factors, and increasing patient demand for elective cesarean delivery.

BACKGROUND: At present there is considerable interest in healthcare administration, among professionals and among the general public concerning the quality of programmes of assisted reproduction. There exist various methods for comparing and analysing the results of clinical activity, with graphical methods being the most commonly used for this purpose. As yet, there is no general consensus as to how the poor performance (PP) or optimum performance (OP) of assisted reproductive technologies should be defined. METHODS: Data from the IVF/ICSI register of the Spanish Fertility Society were used to compare and analyse different definitions of PP or OP. The primary variable best reflecting the quality of an IVF/ICSI programme was taken to be the percentage of singleton births per IVF/ICSI cycle initiated. Of the 75 infertility clinics that took part in the SEF-2003 survey, data on births were provided by 58. A total of 25 462 cycles were analysed. The following graphical classification methods were used: ranking of the proportion of singleton births per cycles started in each centre (league table), Shewhart control charts, funnel plots, best and worst-case scenarios and state of the art methods. RESULTS: The clinics classified as producing PP or OP varied considerably depending on the classification method used. Only three were rated as providing 'PP' or 'OP' by all methods, unanimously. Another four clinics were classified as 'poor' or 'optimum' by all the methods except one. CONCLUSIONS: On interpreting the results derived from IVF/ICSI centres, it is essential to take into account the characteristics of the method used for this purpose.

Gender inequalities in health are a consequence of the basic inequality between men and women in many societies. Despite the importance of socioeconomic factors, women's health is also greatly affected by the extent and quality of health services available to them. Both non-governmental women's organizations and feminist health researchers have in recent years identified major gender inequalities in access to services and in the way men and women are treated by the health care system. Firstly, although women are major health care users as well as providers, they are under-represented in decision-making in health care. Secondly, no justice is done in general to existing differences in position and needs of women and men in defining quality of health care, i.e. gender aspects. Among women's organizations, there is general agreement that "gender sensitive health care should be available, accessible, affordable, appropriate and acceptable". In addition, health care for women should be adequate and not depart from a male model of health and illness. In this paper, we pay attention to inappropriate health care for women on the one hand, as illustrated by the increasing medicalization of women's reproductive life [menstruation, menopause, pregnancy and childbirth and (in)fertility]. On the other hand, we discuss gender bias in the management of serious, life-threatening diseases such as cardiovascular disease, lung cancer, and kidney failure, as a form of inadequate care. These examples are followed by a global vision on quality of care from a gender perspective, as formulated by the women's health care movement in the Netherlands and at the Fourth International Conference on Women in Beijing. If anything, the recommendations agreed upon in Beijing will have to ensure the consolidation and enhancement of good quality health care for women around the world. The final discussion, attempts to give some general recommendations for achieving more adequate (gender sensitive) and appropriate (nonmedicalizing) health care for women. These recommendations pertain to health and health care research, policy, education, and organization from a women's perspective.

Scientific evidence on the impact of small-scale living facilities (SSLFs) on quality of life of nursing home clients remains scarce. In this study a simulation model is developed to examine the performance of SSLFs, in terms of meeting the time preferences of their residents. We model scheduled care using historical data and unscheduled care using a Poisson-Gamma mixture model. The model is used to explore the impact of a change in demand characteristics, duration of care delivery, travel time, allocation flexibility, shifts, number of clients and allocation policy. The results show that to further improve the performance, the focus should lie on: (1) increasing the allocation flexibility of care workers and the number of clients per SSLF, and (2) time dependent staffing. Furthermore, this study shows that simulation is a useful tool for assessing and improving daily nursing home operations. The presented simulation model provides a basis for building a decision support tool for nursing home managers.

The complex formed by chronic illness, episodes of acute illness, physiological disabilities, functional limitations, and cognitive problems is prevalent among frail elderly persons. These individuals rely on assistance from social and health care programs, which in ...

A collaborative project has been initiated to develop a standards-based, comprehensive technology infrastructure that will enable encoding and dissemination of interoperable, electronic clinical practice guidelines (CPG's). Three key deliverables of this large scale ($18M), 3-year project include: An interoperable guideline model, a guideline authoring/encoding workbench, and a guideline deployment system. Our approach will be to employ and extend existing informatics standards, and to collaborate closely with standards development organizations. The project methodology will build on earlier efforts in this field, and will be driven by requirements specific to supporting active deployment of guideline content within clinical information system (CIS) workflow.

The impact of early close relationships on psychological development is one of the enduring questions of developmental psychology that is addressed by attachment theory and research. This essay evaluates what has been learned, and offers ideas for future research, by examining the origins of continuity and change in the security of attachment early in life, and its prediction of later behavior. The discussion evaluates research on the impact of changing family circumstances and quality of care on changes in attachment security, and offers new hypotheses for future study. Considering the representations (or internal working models) associated with attachment security as developing representations, the discussion proposes that (1) attachment security may be developmentally most inßuential when the working models with which it is associated have sufÞciently matured to inßuence other emerging features of psychosocial functioning; (2) changes in attachment security are more likely during periods of representational advance; and (3) parentÐchild discourse and other relational inßuences shape these developing representations after infancy. Finally, other features of early parentÐchild relationships that develop concurrently with attachment security, including negotiating conßict and establishing cooperation, also must be considered in understanding the legacy of early attachments.

A new reimbursement system for general hospitals in Israel was introduced in July 1990. The new system specified that for 15 selected procedures, hospitals would be paid by the insurers prospectively, rather than by the traditional per-diem arrangement. The rates were determined by the Ministry of Health. Henceforth, the number of selected procedures has increased and by now 40 procedures are included. In line with the ever-lasting interest in the effect of financial incentives on suppliers of medical care, the purpose of this paper is to examine the first-year effect of this change on the volume of activity, length of stay, quality of care, and hospitals' real income. We focused on five selected procedures (cholecystectomy, hysterectomy, hip replacement, operations on lens and heart surgeries) performed in the four largest Israeli medical centers (Sheba, Sorasky, Rambam, and Hadassah). The analysis includes more than 17,000 hospitalizations occurring during two years prior to t...

Effective postoperative pain treatment is an essential component to good quality of care. The purpose of this study was to explore nurses' knowledge of and attitudes toward pain in surgical wards before and after implementation of a postoperative management program at a university hospital in Jordan. The program consisted of an education program for nurses, and its effect was evaluated by using a pre-and post-intervention design. Sixty five registered nurses were asked to respond to a 21 items questionnaire, and a total of 240 patients' records were audited. After implementation of the program, the mean scores for all the questionnaire items were found to increase to 75%, with an average of 16/21 for the correct answers. There was a statistically significant difference (p < 0.05) between the number of correct answers between nurses' responses in the pre-intervention phase and their responses in the postintervention phase for most of the questionnaire items. Also, there was a statistically significant improvement in the documentation of patients' care in 85% of the audited patients' records. It was recommended to introduce an acute pain services (APS) using a well established and safe pain management routines to increase the quality of care.

Objective. To examine whether participating in a pressure ulcer prevalence survey and receiving feedback results in an improvement in quality of care. Design. Cross-sectional studies from 1998 to 2002 were compared over time. Setting. Sixty-two acute care hospitals in the Netherlands. Study participants. Patients hospitalized at the moment of the surveys. Interventions. Each hospital was given hospital-specific performance data and national aggregate data, and peer comparisons to improve the quality of care. Main outcome measures. The case-mix-adjusted prevalence of pressure ulcers of grade ≥2, the percentage of high-risk patients receiving adequate prevention, and the total number of enabling conditions present were compared between successive surveys using multi-level analysis, in order to estimate a linear trend model and trend differences for each hospital. Results. The case-mix-adjusted prevalence of pressure ulcers decreased over the 5-year period, while the percentage of patients receiving adequate prevention and the total number of enabling conditions present increased. The total number of enabling conditions had a significant effect on the decrease in case-mix-adjusted prevalence: more enabling conditions led to a lower case-mix-adjusted prevalence (χ 2 = 125; degrees of freedom = 1; P < 0.00). The percentage of patients receiving adequate prevention also had an effect on the change in case-mix-adjusted prevalence, with a higher percentage leading to a lower casemix-adjusted prevalence. This effect, however, was not significant. Conclusions. Monitoring prevalence and giving feedback results in an improvement in quality of care in terms of pressure ulcer prevention. It is very important to continue conducting surveys to avoid attention moving away from this topic, which may in turn lead to a deterioration in the quality of pressure ulcer care. Further research to find the most effective feedback approach is needed.

Background: Psychosocial interventions in long-term care have the potential to improve the quality of care and quality of life of persons with dementia. Our aim is to explore the evidence and consensus on psychosocial interventions for persons with dementia in long-term care. Methods: This study comprises an appraisal of research reviews and of European, U.S. and Canadian dementia guidelines. Results: Twenty-eight reviews related to long-term care psychosocial interventions were selected. Behavioral management techniques (such as behavior therapy), cognitive stimulation, and physical activities (such as walking) were shown positively to affect behavior or physical condition, or to reduce depression. There are many other promising interventions, but methodological weaknesses did not allow conclusions to be drawn. The consensus presented in the guidelines emphasized the importance of care tailored to the needs and capabilities of persons with dementia and consideration of the individual's life context. Conclusions: Long-term care offers the possibility for planned care through individualized care plans, and consideration of the needs of persons with dementia and the individual life context. While using recommendations based on evidence and consensus is important to shape future long-term care, further well-designed research is needed on psychosocial interventions in long-term care to strengthen the evidence base for such care.

Disruptive behaviors have been shown to have a negative impact on work relationships, team collaboration, communication efficiency, and process flow, all of which can adversely affect patient safety and quality of care. Despite the growing recognition of the damage that can be done, there are still pockets of resistance to taking action to address the issue head-on. Given the new call to action from the Joint Commission accreditation standard and the growing public accountability for patient safety, organizations need to recognize the full impact of disruptive behaviors and implement appropriate policies, procedures, and educational programs to raise levels of awareness regarding the seriousness of the issue, hold individuals accountable for their behavior, and provide training and support not only to reduce the incidence and consequences of disruptive events but also to improve efficiency of communication and team collaboration in an effort to improve outcomes of care.

Objective-Staff communication has been shown to influence overall nursing home (NH) performance. However, no empirical studies have focused specifically on the impact of CNA communication on end-of-life (EOL) care processes. This study examines the relationship between CNA communication and nursing home performance in EOL care processes.

Using simulated patients to measure practice in the community pharmacy setting • M a r g a r e t C . Wa t s o n , J o h n R . S k e l t o n , C h r i s t i n e M . B o n d , P h i l C r o f t , C o n n i e M . W i s k i n , J e r e m y M . G r i m s h a

Background: Despite changes to the abortion legislation in South Africa in 1996, barriers to women accessing abortion services still exist including provider opposition to abortions and a shortage of trained and willing abortion care providers. The dearth of abortion providers undermines the availability of safe, legal abortion, and has serious implications for women's access to abortion services and health service planning.

Health care is characterized by highly complex processes of patient care that require unusual amount of communication between different health care professionals of different institutions. Sub-optimal processes can significantly impact on the patient's health, increase the consumption of services and resources and in severe cases can lead to the patient death. For these reasons, requirements engineering for the development of information technology in health care is a complex process as well: without constant and rigorous evaluation, the impact of new systems on the quality of care is unknown and it is possible that badly designed systems significantly harm patients. To overcome these limitations, we present and discuss an approach to requirements engineering that we applied for the development of applications for chemotherapy planning in paediatric oncology. Chemotherapy planning in paediatric oncology is complex and time-consuming and errors must be avoided by all means. In the multi-hospital/multi-trialcentre environment of paediatric oncology, it is especially difficult and time-consuming to analyse requirements. Our approach combines a grounded theory approach with evolutionary prototyping based on the constant development and refinement of a generic domain model, in this case a domain model for chemotherapy planning in paediatric oncology. The prototypes were introduced in medical centres and final results show that the developed generic domain model is adequate.

Family psychoeducation is a highly effective, but underused, evidence-based practice in the treatment of schizophrenia and other serious mental illnesses. This study examined views about family relationships and family participation in care among a sample of 69 consumers with serious mental illness receiving treatment within the Department of Veterans Affairs healthcare system. We found that younger consumers and those with higher levels of psychiatric symptoms were more likely to report family conflict and distress. Of participating consumers, 67% wanted family participation in their psychiatric treatment and those with at least weekly contact with family were more likely to want family participation. Consumers endorsed a number of barriers to family participation in their mental health treatment, including their own concerns about privacy and burdening family and skepticism that family involvement would be helpful. We discuss implications of these findings for the implementation of evidence-based family programs, including efforts toward development of a novel intervention that will address consumers' concerns and promote effective family participation in care.

Background Breast cancer is the commonest cancer of women the world over, and its incidence is rising, especially in developing countries, where the disease poses a major health care challenge. This growing incidence in developing countries reflects the advanced stage at diagnosis, low levels of public awareness of the risk for the disease, and poor medical infrastructure and expertise, with the resultant poor treatment outcomes. Methods This article provides a collective edited summary of the presentations at the symposium titled “Breast Cancer Care in Developing Countries,” held as part of the Breast Surgery International program at the International Surgical week 2007, Montreal, Canada, August 2007. The aim of the presentations was to bring out the diverse clinical pathological and outcomes-related facts of breast cancer care available to women in several countries. As the incidence of breast cancer continues to rise steadily in the developing world, the lack of awareness of this disease and the absence of breast cancer screening programs make it almost certain that the majority of breast cancers are diagnosed at an advanced stage. In addition, the quality of care available for breast cancer patients varies widely according to where the patient is treated. Results Though there are some centers of excellence providing multimodality protocol-based treatment on a par with the best anywhere in the world, most breast cancer patients receive inadequate and inappropriate treatment because of a lack of high-quality infrastructure—and sometimes skills—and, above all, because of limited financial resources. Conclusions In countries where these limitations are present, there is a need to emphasize public health education, promoting early diagnosis. In addition, resources must be directed toward the creation of more public facilities for cancer treatment. As these goals are met, it is likely that there will be a much-needed improvement in breast cancer care in developing countries.

This paper describes the findings of a critical ethnographic research study conducted in an urban long-term care home. While our intention was to learn more about the culture of care, specifically as it relates to mental health care provision, the participants in the study consistently spoke with us about (what we have labeled as) a culture of compliance. In a context where new long-term care legislation is being implemented along with new, standardized resident assessment instruments, gaining a deeper understanding of the (un) intended consequences of government's efforts to ensure a high quality of care is of paramount importance. This research demonstrates how policy-driven structural mechanisms can (re) produce conditions that result in frontline staff being afraid and unable to care, and thus contributes to a better understanding of the lived experience of frontline long-term care staff who find that their caregiving responsibilities are displaced by caregiving accountabilities.

There are not many studies pertaining to the spinal or limb abnormalities in people with intellectual disabilities, without a clear profile of these deformities of them, efforts to understand its characters and improve their quality of life will be impossible.

The concept of pay-for-performance (P4P) encompasses different strategies that aim to stimulate health care quality improvement by remunerating healthcare providers according to their performance in specific measures of efficiency or quality. Although the effectiveness of P4P in improving quality of care is largely unknown, these systems are being widely adopted in the United Kingdom, the United States and other countries, including Spain. The elements of P4P design that are most decisive for the effectiveness of these schemes are as follows: 1) who should receive the incentives, how they should be paid, what should be rewarded, the need to incorporate risk adjustments (mainly if surrogate outcomes are used as indicators) and the need to bear organizational climate and the optimal combination of financial and non-financial incentives in mind. The most important limitations to consider are the following: 1) the exclusive focus on reducing subutilization; 2) the effect on equity; 3) the &amp;amp;amp;amp;amp;quot;magnifying glass&amp;amp;amp;amp;amp;quot; effect; 4) the validity of indicators; 5) the confusion between the recommendations of clinical guidelines and quality indicators; 6) &amp;amp;amp;amp;amp;quot;document engineering&amp;amp;amp;amp;amp;quot;; 7) paternalism; 8) the negative impact on professionalism and clinicians&amp;amp;amp;amp;amp;#39; internal motivation, and 9) the assumption that quality problems result from imperfect individual decisions rather than from an imperfect system.

Anxiety and depressive disorders are highly prevalent disorders and are mostly treated in primary care. The management of these disorders by general practitioners is not always consistent with prevailing guidelines because of a variety of factors. Designing implementation strategies tailored to prospectively identified barriers could lead to more guideline-recommended care. Although tailoring of implementation strategies is promoted in practice, little is known about the effect on improving the quality of care for the early recognition, diagnosis, and stepped care treatment allocation in patients with anxiety or depressive disorders in general practice. This study examines whether the tailored strategy supplemented with training and feedback is more effective than providing training and feedback alone. In this cluster randomised controlled trial, a total of 22 general practices will be assigned to one of two conditions: (1) training, feedback, and tailored interventions and (2) trai...

A correlational design was used to examine nursing staff attitudes and subjective norms manifested in intended and actual care of drug users based on the Theory of Reasoned Action. One hundred and thirty-five nursing staff from three central Israeli hospitals completed a questionnaire examining theory-based variables as well as sociodemographic and professional characteristics. Most respondents reported a high to very high level of actual or intended care of drug users. Nurses&#39; stronger intentions to provide quality care to drug users were associated with more positive attitudes. Nursing staff members had moderately negative attitudes towards drug users. Nurses were found to hold negative stereotypes of drug addict patients and most considered the management of this group difficult. Positive attitudes towards drug users, perceived expectations of others and perceived correctness of the behaviour are important in their effect on the intention of nurses to provide high-quality car...

The National Safety and Quality Health Service Standards requires health service compliance by 2013 and covers several areas including governance arrangements, partnerships with consumers and eight key clinical processes. Nurses in Australia comprise 62% of the hospital workforce, are the largest component and hence play a critical role in meeting these standards and improving the quality of patient care. Several of the standards are influenced by nursing interventions, which incorporate any direct-care treatment that the nurse performs for a patient that may be nurse or physician initiated. The ability for nurses to undertake these interventions is influenced by the hours of care available, the skill mix of the nursing workforce and the environment in which they practice. Taking into consideration the predicted nursing shortages, the challenge to successfully implement the National Safety and Quality Health Service Standards will be great. This paper examines the role of nursing in the delivery of the National Standards, analyses the evidence with regard to nursing-sensitive outcomes and discusses the implications for health service decision makers and policy.

JT03237930 Document complet disponible sur OLIS dans son format d'origine Complete document available on OLIS in its original format DELSA/HEA/WD/HWP(2007)6 Unclassified English -Or. English DELSA/HEA/WD/HWP(2007)6 2 DIRECTORATE FOR EMPLOYMENT, LABOUR AND SOCIAL AFFARIS

The  relationship  between  technological  innovations  job
market and labor process in several areas have been subject of
intense debate.
From a sociological view, technology incorporates machin-
ery, the physical arrangements of hardware, division of labor
and organization of work built into or required for efficient
operation .
The health sector has been influenced by new technologies.
New machines and equipment, new materials and medicines,
advances in genetics and informatics, and the new information
and communication technologies (ICT) have influenced diag-
nostic and multiple therapeutic procedures. The health
care sector has also been influenced by changes in the orga-
nization of work, in the structure and management of institu-
tions, sometimes accompanied by growth in outsourcing
and precarious employment

Classifications of heart muscle diseases have proved to be exceedingly complex and in many respects contradictory. Indeed, the precise language used to describe these diseases is profoundly important. A new contemporary and rigorous classification of cardiomyopathies (with definitions) is proposed here. This reference document affords an important framework and measure of clarity to this heterogeneous group of diseases. Of particular note, the present classification scheme recognizes the rapid evolution of molecular genetics in cardiology, as well as the introduction of several recently described diseases, and is unique in that it incorporates ion channelopathies as a primary cardiomyopathy. (Circulation. 2006;113:1807-1816.) Key Words: AHA Scientific Statements Ⅲ cardiomyopathies Ⅲ arrhythmias Ⅲ terminology Ⅲ genetics C ardiomyopathies are an important and heterogeneous The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on February 1, 2006. A single reprint is available by calling 800-242-8721

One approach to improving the quality of care for severe mental illnesses (SMI) such as schizophrenia is through the improvement of provider competencies; the attitudes, knowledge, and skills needed to deliver high-quality care. This paper describes a new instrument designed to measure such a set of competencies. A total of 341 providers of services to clients with SMI at 38 clinics within 5 publicly financed treatment organizations in 2 western states were asked to complete a paper-and-pencil survey including the new Competency Assessment Instrument (CAI: 15 scales, each assessing a particular provider competency), and additional measures used to establish validity (Recovery Attitude Questionnaire-7, Client Optimism Scale). Seventy-nine percent (N = 269) responded at baseline, 83% (N = 282) responded at 2 weeks. Ninety-seven percent of baseline respondents completed the survey at 2 weeks. Most CAI scales have good internal consistency (Cronbach's αs = .52-.93), test-retest reliability (scales ranged from .42 to .78), and validity, and should be useful in efforts to improve care.

We compared Veterans Health Administration (VHA) residents in community nursing facilities to other residents. We used all admission assessments in the Minimum Data Set throughout the United States during 2000 to identify 7,296 male VHA residents and 159,203 other male residents in community nursing facilities. Male VHA residents were significantly more independent in the self-performance of activities of daily living and less physically disabled than other male residents, with minor differences in cognitive function as measured by a Cognitive Performance Scale. Male VHA residents were more likely to have comorbidities than other male residents. Significantly larger proportions of other male residents than VHA residents received special treatments and procedures, with especially large differences for various therapies (e.g., physical therapy). We found significant differences in the demographic and clinical characteristics of male VHA residents in community nursing facilities compared with other male residents. These differences in the delivery of services may have implications for the quality of care for veterans in this setting.

About 14% of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcohol-use and substance-use disorders, and psychoses. Such estimates have drawn attention to the importance of mental disorders for public health. However, because they stress the separate contributions of mental and physical disorders to disability and mortality, they might have entrenched the alienation of mental health from mainstream efforts to improve health and reduce poverty. The burden of mental disorders is likely to have been underestimated because of inadequate appreciation of the connectedness between mental illness and other health conditions. Because these interactions are protean, there can be no health without mental health. Mental disorders increase risk for communicable and non-communicable diseases, and contribute to unintentional and intentional injury. Conversely, many health conditions increase the risk for mental disorder, and comorbidity complicates help-seeking, diagnosis, and treatment, and influences prognosis. Health services are not provided equitably to people with mental disorders, and the quality of care for both mental and physical health conditions for these people could be improved. We need to develop and evaluate psychosocial interventions that can be integrated into management of communicable and non-communicable diseases. Health-care systems should be strengthened to improve delivery of mental health care, by focusing on existing programmes and activities, such as those which address the prevention and treatment of HIV, tuberculosis, and malaria; gender-based violence; antenatal care; integrated management of childhood illnesses and child nutrition; and innovative management of chronic disease. An explicit mental health budget might need to be allocated for such activities. Mental health affects progress towards the achievement of several Millennium Development Goals, such as promotion of gender equality and empowerment of women, reduction of child mortality, improvement of maternal health, and reversal of the spread of HIV/AIDS. Mental health awareness needs to be integrated into all aspects of health and social policy, health-system planning, and delivery of primary and secondary general health care.

In recent years, information has emerged in the scientific literature regarding the experience of physicians and clinical staff who try to prevent and treat obstetric fistulas at health facilities in developing countries. However, little is known about attempts to match the services they provide with policy and programmatic interventions in the communities they serve. To determine what is known about community involvement in the prevention and treatment of obstetric fistulas, the authors inquired into experiments carried out by EngenderHealth and partners in 15 African and Asian countries. From raw data, gray literature, and personal communications with those working in the field, they learned that engaging the community may be the keystone in the eradication of fistulas in low-resource settings, and they learned how to engage the community.