Equitable health services

A qualitative study on caretakers' perceived need of bed-nets after reduced malaria transmission in Zanzibar, Tanzania
Beer N, Ali AS, Eskilsson H, Jansson A, Abdul-Kadir FM, Rotllant-Estelrich G et al: BMC Public Health 12:606, 3 August 2012

To explore perceptions of malaria and utilisation of insecticide-treated bed-nets after a noticeable reduction in malaria incidence in Zanzibar, the authors of this study conducted 19 in-depth interviews with caretakers of children under five in North A district on the island. They found that awareness of malaria among caretakers was high but the illness was now seen as easily curable and uncommon. The discomfort of sleeping under a net during the hot season was identified as the main barrier to consistent bed-net usage. The main cue to using a bed-net was high mosquito density, and children were prioritised when it came to bed-net usage. Caretakers had high perceived self-efficacy and did not find it difficult to use bed-nets. Indoor Residual Spraying (IRS), which was recognised as an additional means of mosquito prevention, was not identified as an alternative for bed-nets. A barrier to net ownership was the increasingly high cost of bed-nets. The authors call on the government to continue providing bed nets through sustainable and affordable delivery mechanisms.

A quasi-experimental evaluation of an interpersonal communication intervention to increase insecticide-treated net use among children in Zambia
Keating J, Hutchinson P, Miller JM, Bennett A, Larsen DA, Hamainza B et al: Malaria Journal 11(313), 7 September 2012

In this study, researchers evaluated the effect of a community health worker-based, interpersonal communication campaign for increasing insecticide-treated mosquito net (ITN) use among children in Luangwa District, Zambia, an area with near universal coverage of ITNs and moderate to low malaria parasite prevalence. Results indicated that ITN use among children younger than five years old in households with one ITN increased overall from 54 % in 2008 to 81 % in 2010. However, there was no difference in increase between the treatment and control arms in 2010. ITN use also increased among children five to 14 years old from 37 % in 2008 to 68 % in 2010. There was no indication that the community health worker-based intervention activities had a significant effect on increasing ITN use in this context, over and above what is already being done to disseminate information on the importance of using an ITN to prevent malaria infection. Contamination across control communities, coupled with linear settlement patterns and subsequent behavioural norms related to communication in the area, likely contributed to the observed increase in net use and null effect in this study, the authors conclude.

A realist review of mobile phone-based health interventions for non-communicable disease management in sub-Saharan Africa
Opoku D; Stephani V; Quentin W: BMC Medicine 15 (24), doi: 10.1186/s12916-017-0782-z, 2017

The prevalence of non-communicable diseases (NCDs) is increasing in sub-Saharan Africa. At the same time, the use of mobile phones is rising, expanding the opportunities for the implementation of mobile phone-based health (mHealth) interventions. This review aims to understand how, why, for whom, and in what circumstances mHealth interventions against NCDs improve treatment and care in sub-Saharan Africa. Four main databases (PubMed, Cochrane Library, Web of Science, and Google Scholar) and references of included articles were searched for studies reporting effects of mHealth interventions on patients with NCDs in sub-Saharan Africa. All studies published up until May 2015 were included in the review. Following a realist review approach, middle-range theories were identified and integrated into a Framework for Understanding the Contribution of mHealth Interventions to Improved Access to Care for patients with NCDs in sub-Saharan Africa. The main indicators of the framework consist of predisposing characteristics, needs, enabling resources, perceived usefulness, and perceived ease of use. Studies were analyzed in depth to populate the framework. The search identified 6137 titles for screening, of which 20 were retained for the realist synthesis. The contribution of mHealth interventions to improved treatment and care is that they facilitate (remote) access to previously unavailable (specialized) services. Three contextual factors (predisposing characteristics, needs, and enabling resources) influence if patients and providers believe that mHealth interventions are useful and easy to use. Only if they believe mHealth to be useful and easy to use, will mHealth ultimately contribute to improved access to care. The analysis of included studies showed that the most important predisposing characteristics are a positive attitude and a common language of communication. The most relevant needs are a high burden of disease and a lack of capacity of first-contact providers. Essential enabling resources are the availability of a stable communications network, accessible maintenance services, and regulatory policies. The authors propose that policy makers and program managers consider predisposing characteristics and needs of patients and providers as well as the necessary enabling resources prior to the introduction of an mHealth intervention. They argue that researchers would benefit from placing greater attention on the context in which mHealth interventions are being implemented instead of focusing (too strongly) on the technical aspects of these interventions.

A review of health system infection control measures in developing countries: what can be learned to reduce maternal mortality
Hussein J, Mavalankar DV, Sharma S and D'Ambruoso L: Globalization and Health 7(14), May 2011

According to this paper, puerperal sepsis is an infection contracted during childbirth and one of the commonest causes of maternal mortality in developing countries, despite the discovery of antibiotics over eighty years ago. Some developing countries have recently experienced increased use of health facilities for labour and delivery care and there is a possibility that this trend could lead to rising rates of puerperal sepsis. Drug and technological developments need to be combined with effective health system interventions to reduce infections, including puerperal sepsis. The authors review health system infection control measures pertinent to labour and delivery units in developing country health facilities. Organisational improvements, training, surveillance and continuous quality improvement initiatives, used alone or in combination have been shown to decrease infection rates in some clinical settings. There is limited evidence available on effective infection control measures during labour and delivery and from low-resource settings. The authors argue that a health systems approach is necessary to reduce maternal mortality and the occurrence of infections resulting from childbirth. Organisational and behavioural change underpins the success of infection control interventions. A global, targeted initiative could raise awareness of the need for improved infection control measures during childbirth.

A review of internal medicine re-admissions in a peri-urban South African hospital
Stanley A, Graham N, Parrish A: South African Medical Journal 98(4):291-294, 2008

The re-admission rate and the number of preventable re-admissions in a secondary-level South African hospital were measured to identify factors predictive of re-admission. The admission register for the medical wards at Cecilia Makiwane Hospital (CMH) was used to identify re-admitted patients, whose folders were then reviewed. A comparison group of patients who were not re-admitted was randomly generated from the same register. One in twelve general medical patients was readmitted. Chronic diseases and inadequate patient education and discharge planning accounted for the largest group of re-admissions in older patients. Re-admission of HIV/AIDS patients has generated a second peak in younger individuals, and the impact of the antiretroviral roll-out on admission rates warrants further scrutiny.

A stitch in time: A cross-sectional survey looking at long-lasting insecticide-treated bed net ownership, utilisation and attrition in SNNPR, Ethiopia
Batisso E, Habte T, Tesfaye G, Getachew D, Tekalegne A, Kilian A et al: Malaria Journal 11(183), 7 June 2012

Since 2002, an estimated 4.7 million long-lasting insecticide-treated nets (LLINs) have been distributed in the Southern Nations, Nationalities and Peoples Region (SNNPR) of Ethiopia among a population of approximately 10 million people at risk for contracting malaria. This study sought to determine the status of current net ownership, utilisation and rate of long-lasting insecticide-treated nets (LLIN) loss in the previous three years. A total of 750 household respondents were interviewed in SNNPR. Approximately 67.5% of households currently owned at least one net. An estimated 31% of all nets owned in the previous three years had been discarded by owners, most of whom considered the nets too torn, old or dirty. Households reported that one-third of nets (33.7%) were less than one year old when they were discarded. These results suggest that the life span of nets may be shorter than previously thought, with little maintenance by their owners. With the global move towards malaria elimination it makes sense to aim for sustained high coverage of LLINs, the authors argue. However, in the current economic climate, it also makes sense to use simple tools and messages on the importance of careful net maintenance, which could increase their lifespans.

A stitch in time: A cross-sectional survey looking at long-lasting insecticide-treated bed net ownership, utilisation and attrition in SNNPR, Ethiopia
Batisso E, Habte T, Tesfaye G, Getachew D, Tekalegne A, Kilian A et al: Malaria Journal 11(183), 7 June 2012

Since 2002, an estimated 4.7 million long-lasting insecticide-treated nets (LLINs) have been distributed in the Southern Nations, Nationalities and Peoples Region (SNNPR) of Ethiopia among a population of approximately 10 million people at risk for contracting malaria. This study sought to determine the status of current net ownership, utilisation and rate of long-lasting insecticide-treated nets (LLIN) loss in the previous three years. A total of 750 household respondents were interviewed in SNNPR. Approximately 67.5% of households currently owned at least one net. An estimated 31% of all nets owned in the previous three years had been discarded by owners, most of whom considered the nets too torn, old or dirty. Households reported that one-third of nets (33.7%) were less than one year old when they were discarded. These results suggest that the life span of nets may be shorter than previously thought, with little maintenance by their owners. With the global move towards malaria elimination it makes sense to aim for sustained high coverage of LLINs, the authors argue. However, in the current economic climate, it also makes sense to use simple tools and messages on the importance of careful net maintenance, which could increase their lifespans.

A systematic review of delay in the diagnosis and treatment of tuberculosis
Storla DG, Yimer S, Bjune GA: BMC Public Health, 2008

This paper reviews 58 studies that assess the delay in the diagnosis and treatment of tuberculosis (TB). Delay in diagnosis can affect disease prognosis at the individual level and enhance transmission of TB within the community. The paper identifies the main factors associated with diagnostic delay. These include HIV; coexistence of chronic cough and/or other lung diseases; geographical barriers; rural residence; poverty; old age; female sex; alcoholism and substance abuse; low educational level; low awareness of TB; and stigma. The paper concludes that the core problem in delay of diagnosis and treatment appears to be a vicious cycle of repeated visits at the same healthcare level, resulting in non-specific antibiotic treatment, incorrect diagnosis and failure to access specialised TB services. Three groups of healthcare providers were identified as sources of this vicious cycle: primary-level government health posts who have limited diagnostic facilities and poorly trained personnel; private practitioners with low awareness of TB and unqualified vendors and traditional practitioners.

A Wake-up Call - Lessons from Ebola for the world's health systems
Wright S; Hanna L; Mailfert M; Gushulvili D; Kite G: Save the Children 2015

Ebola has taken a dreadful toll in the three West African countries hit by the current outbreak – Guinea, Sierra Leone and Liberia. In this report, Save the Children documents the existing weaknesses of the health services in the three main countries affected by Ebola. There is broad agreement that the Ebola crisis was not quickly contained, reversed or mitigated because national health systems in these countries were dangerously under-resourced, under-staffed and poorly equipped. The virus was able to spread, in part, due to the poor state of these health services, which were quickly overwhelmed and lacked the ability to cope with a major disease outbreak. This inability to cope with a major health emergency reflects a similar inability to cope with the daily health needs of their populations over the longer term. The authors argue that one of the most important lessons from the Ebola crisis is the need to build comprehensive health services with sufficient funding, staff and equipment, to deal with everyday problems as well as infectious
disease outbreaks.

Acceptability of evidence-based neonatal care practices in rural Uganda: Implications for programming
Waiswa P, Kemigisa M, Kiguli J, Naikoba S, Pariyo GW and Peterson S: BMC Pregnancy and Childbirth 8(21), 21 June 2008

Although evidence-based interventions to reach the Millennium Development Goals for Maternal and Neonatal mortality reduction exist, they have not yet been operationalised and scaled up in Sub-Saharan African cultural and health systems. A key concern is whether these internationally recommended practices are acceptable and will be demanded by the target community. The researchers explored the acceptability of these interventions in two rural districts of Uganda; conducted ten focus group discussions consisting of mothers, fathers, grand parents and child minders (older children who take care of other children); and ten key informant interviews with health workers and traditional birth attendants. Most maternal and newborn recommended practices are acceptable to both the community and to health service providers. However, health system and community barriers were prevalent and will need to be overcome for better neonatal outcomes. Pregnant women did not comprehend the importance of attending antenatal care early or more than once unless they felt ill. Women prefer to deliver in health facilities but most do not do so because they cannot afford the cost of drugs and supplies which are demanded in a situation of poverty and limited male support. Postnatal care is non-existent. For the newborn, delayed bathing and putting nothing on the umbilical cord were neither acceptable to parents nor to health providers, requiring negotiation of alternative practices. Communities associate the need for antenatal care attendance with feeling ill, and postnatal care is non-existent in this region. Health promotion programs to improve newborn care must prioritise postnatal care, and take into account the local socio-cultural situation and health systems barriers including the financial burden. Male involvement and promotion of waiting shelters at selected health units should be considered in order to increase access to supervised deliveries. Scale-up of the evidence based practices for maternal-neonatal health in Sub-Saharan Africa should follow rapid appraisal and adaptation of intervention packages to address the local health system and socio-cultural situation.

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