The aim of this paper was to describe the pre-operative surgical case mix among patients undergoing cataract extraction and explore associations between case mix, country level of development (as measured by the Human Development Index, or HDI) and cataract surgery rates (CSRs). Ophthalmologists at 112 eye hospitals (54% of them non-governmental) in 50 countries provided data on 11,048 cataract procedures over nine months in 2008. Patients whose visual acuity (VA) before surgery was < 6/60 in the better eye comprised 47% of the total case mix in poorly developed countries and 1% in developed countries. Overall, 72% of the eyes undergoing surgery had a VA < 6/60. Very low VA before cataract surgery was strongly associated with poor development at the country level and inversely associated with national CSRs. The researchers conclude that the proportion of patients with very poor preoperative VA is a simple indicator that can be easily measured periodically to monitor progress in ophthalmological services. Additionally, the internet can be an effective tool for developing and supporting an ophthalmological research network capable of providing a global snapshot of service activity, particularly in developing countries.
Equitable health services
The aim of this paper is to show that current provider-centred models of chronic care are not adequate and to propose 'full self-management' as an alternative for low-income countries. People with chronic life-long conditions need to 'rebalance' their life in order to combine the needs related to their chronic condition with other elements of their life, the authors argue. They have a crucial role in the management of their condition and the opportunity to gain knowledge and expertise in their condition and its management. Therefore, people with chronic life-long conditions should be empowered so that they become the centre of management of their condition. In full self-management, patients take full responsibility for their condition, supported by peers, professionals and information and communication tools. The authors examine two current trends to enhance the capacity for self-management and coping: the emergence of peer support and expert-patient networks, and the development and distribution of smart phone technology.
Modern medicine is often accused by diverse critics of being ‘too materialistic’ and therefore insufficiently holistic and effective. Yet, this critique can be misleading, the authors of this paper argue, as it is dependent upon the ambiguous meanings of ‘materialism’. The term can refer to the prevalence of financial concerns in driving medical practice or it can refer to ‘mechanistic materialism,’ the patient viewed as a body-machine. In each case, this article shows that this represents not authentic ‘materialism’ at play, but a focus upon high-level abstractions. ‘Bottom-line’ financial or diagnostic numbers can distract practitioners from the embodied needs of sick patients. In this sense, medical practice is not materialist enough. Through a series of clinical examples, the authors explore how an authentic materialism would look in current and future practice. They examine the use of prayer/comfort shawls at the bedside, the redesign of hospitals and nursing homes as enriched healing environments, and a paradigmatic medical device - the implantable cardioverter defibrillator - as it might be presented to patients, in contrast to current practice.
The authors of this study examined the feasibility of using community health workers (CHWs) to implement cardiovascular disease (CVD) prevention programmes within faith-based organisations in Accra, Ghana. Faith-based organisation capacity, human resources, health programme sustainability/barriers and community members’ knowledge were evaluated. Data on these aspects were gathered through a mixed method design consisting of in-depth interviews and focus groups with 25 church leaders and health committee members from five churches, and of a survey of 167 adult congregants from two churches. Findings indicated that the delivery of a CVD prevention programme in faith-based organisations by CHWs is feasible. Many faith-based organisations already provide health programmes for congregants and involve non-health professionals in their health-care activities, and most congregants have a basic knowledge of CVD. Yet despite the feasibility of the proposed approach to CVD prevention through faith-based organisations, sociocultural and health-care barriers such as poverty, limited human and economic resources and limited access to health care could hinder programme implementation.
The objective of this study was to assess adherence to community-based directly observed treatment (DOT) among Tanzanian tuberculosis patients using the Medication Event Monitoring System (MEMS) and to validate alternative adherence measures for resource-limited settings using MEMS as a gold standard. This was a longitudinal pilot study of 50 patients recruited consecutively from one rural hospital, one urban hospital and two urban health centres. Treatment adherence was monitored with MEMS and the validity of a range of adherence measures was assessed, including the Morisky scale, adapted AIDS Clinical Trials Group (ACTG) adherence questionnaire, pill counts and medication refill visits. The mean adherence rate in the study population was 96.3%. Adherence was less than 100% in 70% of the patients, less than 95% in 21% of them, and less than 80% in 2%. The ACTG adherence questionnaire and urine colour test had the highest sensitivities but lowest specificities. The Morisky scale and refill visits had the highest specificities but lowest sensitivities. Pill counts and refill visits combined, used in routine practice, yielded moderate sensitivity and specificity, but sensitivity improved when the ACTG adherence questionnaire was added. In conclusion, patients on community-based DOT showed good adherence in this study. The combination of pill counts, refill visits and the ACTG adherence questionnaire could be used to monitor adherence in settings where MEMS is not affordable.
In this study, researchers investigated community case management of malaria (CCMm) through community medicine distributors (CMD) in urban areas in Ghana, Burkina Faso, Ethiopia and Malawi. CMDs were trained to educate caregivers, diagnose and treat malaria cases in <5-year olds with ACT. Household surveys, focus group discussions and in-depth interviews were used to evaluate impact. In all sites, interviews revealed that caregivers' knowledge of malaria signs and symptoms improved after the intervention. Preference for CMDs as providers for malaria increased in all sites. In addition, 9,001 children with an episode of fever were treated by 199 CMDs in the five study sites and, of these, 6,974 were treated with an ACT and 6,933 (99%) were prescribed the correct dose for their age. Fifty-four percent of the 3,025 children for which information about the promptness of treatment was available were treated within 24 hours from the onset of symptoms. The researchers conclude that the concept of CCMm in an urban environment was positive, and caregivers were generally satisfied with the services. Quality of services delivered by CMDs and adherence by caregivers are similar to those seen in rural CCMm settings. The proportion of cases seen by CMDs, however, tended to be lower than was generally seen in rural CCMm.
Physical inactivity has been identified as the fourth leading risk factor for the prevention of non-communicable diseases (NCDs), preceded only by tobacco use, hypertension, and high blood glucose levels, and accounting for more than three million preventable deaths globally in 2010. Physical inactivity is a global public health priority but, in most countries, this has not yet resulted in widespread recognition nor specific physical activity–related policy action at the necessary scale, the authors of this article argue. The authors identify and discuss eight possible explanations why inactivity is overlooked and the need for more effective communication on the importance of physical activity in the NCD prevention context. Although not all of the issues identified will be relevant for any one country, it is likely that at different times and in different combinations these problems continue to delay national-level progress on addressing physical inactivity in many countries. The authors confirm that there is sufficient evidence to act, and that much better use of well-planned, coherent communication strategies are needed in most countries and at the international level. Significant opportunities exist. The Toronto Charter on Physical Activity and the Seven Investments that Work are two useful tools to support increased advocacy on physical activity within and beyond the context of the crucial UN High-Level Meeting on NCDs in September 2011.
Despite the availability of many treatment options, depressive disorders remain a global public health problem, according to this study. In developing countries, the World Health Organisation estimates that less than 10% of those suffering from depression receive proper care due to poverty, stigma and lack of governmental mental health resources and providers. Positive activity interventions (PAIs) are a type of low-cost intervention that teaches individuals ways to increase their positive thinking, positive emotions and positive behaviours. In this article, the authors review the relevant literature on the effectiveness of various types of PAIs, draw on social psychology, affective neuroscience and psychophamacology research to propose neural models for how PAIs might relieve depression, and discuss the steps needed to translate the potential promise of PAIs as clinical treatments for individuals with major and minor depressive disorders.
In 2009, as part of a strategic planning process, Makerere University College undertook a qualitative study to examine care and service provision at Mulago National Referral Hospital (MNRH), identify challenges, gaps, and solutions, and explore how the University could contribute to improving care and service delivery at MNRH. Twenty-three key informant interviews and seven focus group discussions were conducted with nurses, doctors, administrators, clinical officers and other key stakeholders. Participants identified a number of challenges to care and service delivery at MNRH, including resource constraints, staff inadequacies, overcrowding, a poorly functioning referral system, limited quality assurance, and a cumbersome procurement system. They also pointed to insufficiencies in the teaching of professionalism and communication skills to students, and patient care challenges that included lack of access to specialised services, risk of infections, and inappropriate medications. The authors recommend addressing these barriers by strengthening the relationship between the hospital and Makerere. Strategic partnerships and creative use of existing resources, both human and financial, could improve quality of care and service delivery.
The objective of this study was to determine whether community-based health workers in a rural region of Ethiopia can provide injectable contraceptives to women with similar levels of safety, effectiveness and acceptability as health extension workers. The researchers examined the provision of injectable contraceptives by community-based reproductive health agents (CBRHAs). A total of 1,062 women participated in the study. Compared with health post clients, the clients of CBRHAs were, on average, slightly older, less likely to be married and less educated, and they had significantly more living children. Women seeking services from CBRHAs were also significantly more likely to be using injectable contraceptives for the first time; health post clients were more likely to have used them in the past. In addition, clients of CBRHAs were less likely to discontinue using injectable contraceptives over three injection cycles than health post clients. In conclusion, receiving injectable contraceptives from CBRHAs proved as safe and acceptable to this sample of Ethiopian women as receiving them in health posts from health extension workers.