International Health

Editorial Board

2012-03-01

Comparing key informants to health workers in identifying children in need of surgical eye care services

Fortunate Shija, Sylvia Shirima, Susan Lewallen, Paul Courtright — 2011-11-11

Summary: The objective of the study was to compare the productivity of key informants (KIs) and dedicated health workers (HWs) in identifying children with surgical eye care needs. In two regions of Tanzania, KIs and HWs were trained to identify and register children with severe visual impairment or blindness, with the objective of providing them with surgical eye care services. Identified children were examined at predetermined sites. The total numbers of children in need of surgical services identified by KIs and HWs were compared to measure their relative efficacy. A total of 197 KIs and 63 HWs were trained in the two regions. Five hundred and forty-nine children were identified by KIs and 22 children were identified by HWs: KIs were three times more productive than the HWs. Most of the children identified and examined had serious eye pathology and received surgery or low vision services. The cost per child found was significantly less for children found by KI compared to HW. The study indicates that, in rural Africa, finding children in need of surgical and low vision interventions and ensuring that they are properly screened appears to require community-based efforts.

Knowledge, attitudes and practices of rabies prevention and dog bite injuries in urban and peri-urban provinces in Cambodia, 2009

Meg Lunney, Sonia J.S. Fèvre, Enid Stiles, Sowath Ly, Sorn San, Sirenda Vong — 2012-02-10

Abstract: Rabies remains a major public health issue despite the existence of well established prevention and treatment protocols. Knowledge and methods of practice were evaluated in an urban and peri-urban province of Cambodia (Phnom Penh and Kandal, respectively). The majority of respondents (93.2%; 233/250) had heard of the disease rabies, of whom only 77.3% (180/233) knew it was fatal to humans. In addition, only 51.9% (121/233) were aware of the vaccine for dogs. The proportion of the population that reported a dog bite (2004–2009) was similar for Phnom Penh and Kandal. Nearly one-half of all victims (37/75) sought treatment at the Institut Pasteur–Cambodia (IPC) clinic, followed by a private clinic (19/75), a hospital (6/75) and traditional medicine (4/75); 7 victims sought no treatment and 2 reported other. Overall, children aged <15 years reported a significantly greater proportion of dog bite victims than adults aged ≥15 years [10.0% (28/280) vs 4.4% (47/1059), respectively]. Nearly all dog owners agreed to pay for their dogs’ vaccination (96.5%; 136/141) and to use a collar (94.3%; 133/141). Only 41.8% (59/141) and 51.8% (73/141) would pay to have their dogs spayed and neutered, respectively. Further community education on the prevention of rabies transmission is needed. Focusing on responsible dog ownership and the importance of both the prevention and immediate treatment following a dog bite is essential to reduce rabies infection in Cambodia.

Nomadic Fulani communities manage malaria on the move

O.B. Akogun, A.O. Adesina, S. Njobdi, O. Ogundahunsi — 2011-11-11

Abstract: As in other public health efforts, the current promotion of insecticide-treated net (ITN) usage and prompt treatment of malaria has left the nomadic populations behind. The hypothesis that nomads can apply the community-directed intervention (CDI) strategy for fever management in children under-5 was tested among nomadic Fulani communities in northeastern Nigeria. Twenty camps selected representatives who were trained to provide artemisinin-based combination therapy and ITNs to their members. Coverage was compared with existing practice in 20 other nomadic Fulani communities. At baseline, none of the camps had ITNs, and antimalarial usage was only 2.7% in intervention camps and 5.8% in comparison camps. The nomads redesigned the negotiated intervention delivery approach to suit their culture. Within 12 months antimalarial usage and appropriate management of malaria in children under-5 reached 88.0% and 81.7%, respectively, and within 24 months they reached 87.9% and 86.1%, respectively, surpassing the Roll Back Malaria target of 80% coverage by 2011. In contrast, usage was <5% in the comparison camps. ITN possession reached 66.7% and 73.2% in the first and second years, respectively, within intervention camps, but was unchanged in comparison camps. However, ITN usage remained low at 21.7% in the second year (P<0.05). When empowered, nomads will appropriately manage malaria using the CDI approach.

Improving health service delivery organisational performance in health systems: a taxonomy of strategy areas and conceptual framework for strategy selection

2011-11-11

Abstract: Health systems strengthening (HSS) is a priority for global health funders, policy-makers and practitioners. Although many HSS efforts have focused on policy levers such as financing approaches, payment schemes or regulatory reforms, less attention has been directed to targeting the organisations that deliver health services such as hospitals, health centres and clinics. Evidence suggests that the impact of organisation-level interventions varies by context; however, we lack a general framework for integrating organisational context into performance improvement strategies for health service delivery organisations. Drawing on open systems theories from organisational behaviour and management as well as a review of 181 empirical studies of health service delivery organisations in low- and middle-income countries, we propose a taxonomy of seven strategy areas for improving organisational performance as well as a multistage conceptual framework for selecting among them. We propose that the choice of strategy for improving health service delivery organisational performance should be informed by: (i) the root cause of the organisation's performance gap; (ii) the environmental conditions facing the organisation; and (iii) the implementation capability of the organisation. We also highlight conditions under which different strategy areas may be expected to be optimally effective. The approaches presented in this paper offer a way for health system decision-makers and researchers to systematically assess and incorporate organisational context in the process of developing strategies to improve the performance of health service delivery organisations and, ultimately, of health systems.

HIV as a risk factor for cardiac disease in Botswana: a cross-sectional study

Thomas Schwartz, Girgis Magdi, Tore W. Steen, Ivar Sjaastad — 2012-02-10

Abstract: The primary objective of this study was to assess how HIV has influenced the spectrum of heart diseases in Botswana and to examine the HIV prevalence among patients with cardiomegaly. The secondary objective was to evaluate the value of the cardiothoracic (CT) ratio on chest radiography (CXR) as a screening tool for cardiac disease. In total, 179 patients (age 14–97 years) with cardiomegaly (all CT ratios >0.53 on CXR) and known HIV status were referred to Botswana's sole hospital-based echocardiographic centre. Clinical examination and echocardiography were performed. Cardiomyopathy (36.9%), pericarditis (21.2%), hypertensive heart disease (14.0%), rheumatic heart disease (8.4%) and right-sided heart failure (6.7%) were the main causes of cardiomegaly; only two patients had a normal echocardiogram. The HIV prevalence was higher than in the general population [59% vs 25%; relative risk (RR) of HIV infection compared with the general population 2.4, 95% CI 2.1–2.7]. HIV infection was strongly associated with pericarditis (RR 3.3, 95% CI 2.8–3.8) and cardiomyopathy (RR 2.9, 95% CI 2.4–3.5). These data suggest an increased risk of non-ischaemic heart disease, in particular pericarditis and cardiomyopathy, among HIV-infected patients. The CT ratio on CXR had high specificity in detecting severe heart disease and can be a useful screening tool in areas with limited resources.

Cost-effectiveness analysis of three health interventions to prevent malaria in pregnancy in an area of low transmission in Uganda

Kristian Schultz Hansen, Richard Ndyomugyenyi, Pascal Magnussen, Siân E. Clarke — 2012-02-10

Abstract: Pregnant women and their unborn children are vulnerable to malaria, increasing the risk of maternal anaemia, low birthweight (LBW) and intrauterine growth retardation. There is little evidence on the cost-effectiveness of intermittent preventive treatment in pregnancy (IPTp) and insecticide-treated bednets (ITN) in areas of low transmission. A randomised controlled trial with three arms was conducted in antenatal clinics in Kabale District (Uganda), an epidemic-prone highland area of low malaria transmission. The interventions were: (i) IPTp with sulfadoxine/pyrimethamine (SP) given twice during pregnancy (IPTp-SP); (ii) ITNs alone; and (iii) a combined intervention with both ITNs and IPTp-SP. Primary health outcomes were LBW and maternal anaemia. The costs of providing IPTp-SP and ITNs as well as treatment of malaria episodes were captured from all health centres in the study area. There were no significant differences in health outcomes among the three interventions. The cost-effectiveness analysis and sensitivity analyses performed did not provide convincing support for replacing IPTp-SP (current policy) by ITNs alone or by a combined intervention in this low-transmission setting on economic grounds. The cost per pregnant woman of providing the services was lowest for the IPTp-SP intervention (US$0.79 per woman) followed by ITNs (US$1.71) and the combined intervention of IPTp-SP+ITNs (US$2.48). The relative cost-effectiveness of antenatal distribution of ITNs might improve if the cost savings accruing from continued use of a long-lasting insecticidal net after pregnancy as well as positive externalities were also taken into account, and this warrants further study. [ClinicalTrials.gov identifier: NCT00142207]

Approaching the community about screening children for a multicentre malaria vaccine trial

2011-12-19

Abstract: Community sensitisation, as a component of community engagement, plays an important role in strengthening the ethics of community-based trials in developing countries and is fundamental to trial success. However, few researchers have shared their community sensitisation strategies and experiences. We report on our perspective as researchers on the sensitisation activities undertaken for a phase II malaria vaccine trial in Kilifi District (Kenya) and Korogwe District (Tanzania), with the aim of informing and guiding the operational planning of future trials. We report wide variability in recruitment rates within both sites; a variability that occurred against a backdrop of similarity in overall approaches to sensitisation across the two sites but significant differences in community exposure to biomedical research. We present a range of potential factors contributing to these differences in recruitment rates, which we believe are worth considering in future community sensitisation plans. We conclude by arguing for carefully designed social science research around the implementation and impact of community sensitisation activities.

The effects of standardised protocols of obstetric and neonatal care on perinatal and early neonatal mortality at a rural hospital in Tanzania

Carsten Krüger, Mauri Niemi, Hans Espeland, Naftali Naman, Isaack Malleyeck — 2011-12-12

Summary: The care of pregnant women and neonates in peripheral hospitals in many developing countries is in a critical state. Through a retrospective analysis we assessed the effects of the introduction of standardised protocols in obstetric and neonatal care (implementation from 1998 onwards) on perinatal and neonatal outcomes of all deliveries over seven years (1996–2002) at a first-referral hospital in rural Tanzania. In all, there were 18026 deliveries (18316 live births and 606 stillbirths). Perinatal mortality rates (PMR) varied from 42.8–54.5/1000 live births during the years. Early neonatal mortality rates (eNMR) fell from 21.9/1000 live births in 1996 to 14.8/1000 live births in 2002 (all p>0.05). Fresh stillbirth rates decreased over time (p=0.041), however macerated stillbirth rates increased during the second half of the period (p=0.067). Sixty-two to seventy-two percent of eNMR occurred on the first day of life (p<0.001). Maternal mortality ratio declined from 729/100000 live births in 1996 to 119/100000 live births in 2002 (p=0.002). Our clinical project was associated with a reduction of PMR and eNMR (and maternal mortality ratios), but with considerable fluctuations during the years. Improving obstetric and neonatal care in the hospital setting in developing countries is essential, but needs long-term commitment and support.

Acceptability of coitally-associated versus daily use of 1% tenofovir vaginal gel among women in Pune, India

Sanjay Mehendale, Swapna Deshpande, Rewa Kohli, Sharon Tsui, Elizabeth Tolley — 2012-02-10

Abstract: This study reports on the acceptability of 1% tenofovir microbicide gel among participants randomised to the coitally-associated use (n=50) or daily use (n=50) arms of a Phase II clinical trial in Pune, India. In a 6-month follow-up study, information on behavioural domains was collected on a 6-point Likert scale and gel acceptability was measured on a 5-point Likert scale. Random intercept logistic modelling was performed to examine the simultaneous effects of study arm, follow-up time, sociodemographic factors and behavioural domains on gel acceptability. The mean age of female participants was 32.7 years. Women in both study arms had similar sociodemographic profiles. Women liked features such as easy use of the gel and its protective effect against HIV. Messiness was the most disliked feature. Gel acceptability increased during subsequent follow-up visits in both arms, especially in the coitally-associated use arm. Non-acceptability of the gel was almost two and a half times higher in daily users (adjusted odds ratio 2.55, 95% CI 1.18–5.51; p=0.017). Acceptability differed significantly between the two study arms at 2 months (68% vs 40%; p=0.006) and 6 months (64% vs 46%; p=0.07). Acceptability was significantly lower in those participants who reported ‘messiness’ as the most disliked feature (odds ratio 2.42, 95% CI 1.02–5.72; p=0.045). In conclusion, microbicides were more acceptable in coitally-associated users than in daily users. Leakage was a problem that requires attention. Positioning of the product in a setting such as India where the majority of decision-making is done by men would need extensive and systematic education of men.

The role of private health facilities in the provision of malaria case management and prevention services in four zones of Oromia Regional State, Ethiopia

2011-12-19

Summary: Little is known about the contribution of the private health sector in managing malaria cases and contributing to malaria prevention and control efforts in Ethiopia. We assessed 102 private health facilities and 92 drug outlets in 20 districts of Oromia Regional State, Ethiopia, for their provision of malaria-specific services. Of the assessed health facilities 86% provided such services. Diagnosis was largely clinical, with only 31% and 15% of all health facilities seen using rapid diagnostic tests and microscopy, respectively. Facilities had chloroquine, artemether-lumefantrine, quinine and sulfadoxine-pyremethamine. Gaps were seen in provision of guidelines and other malaria-related materials, training of facility staff and supervision. Inclusion of the private health sector in malaria control program is crucial to expand current malaria prevention and control efforts in Ethiopia.

Evaluation of scaling-up should take into account financial access: Comment on: Evaluating the scale-up for maternal and child survival: a common framework

David Hercot, Raoul Bermejo, Yibeltal Assefa, Wim Van Damme — 2012-02-10

We appreciate the proposition of Bryce et al. to extend the scope of evaluation beyond the mere impact of a programme. With a view to refining the framework further we propose a possible extension of the framework and discuss the inclusion of a key outcome.