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.
Equitable health services
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.
This report on public healthcare provision in South Africa revealed deficiencies in the national health care system, including a shortage of ambulances, clinics, medical personnel and medication. More than 400 community-based and nongovernment organisations, human rights and health organisations and almost every district municipality across the country participated in the assessment. Patients complained of verbal abuse, discrimination and violation of patient rights, especially with regard to confidentiality. The environmental causes of illness, including poor water quality and a lack of proper sanitation was commonly noted, putting pressure on the health system. Deep concern was also expressed that those suffering from chronic illnesses needed access to social and financial support as well as medical treatment. The consultations exposed an absence of effective monitoring and evaluation systems. There are no central points where complaints can be lodged, the report notes. The report has been released ahead of the scheduled parliamentary debates on the proposed National Health Insurance (NHI) scheme.
This qualitative study was conducted in two malaria-endemic regions of Kenya - South Coast and Busia. Participant selection was purposive and criterion based. A total of 20 focus group discussions, 22 in-depth interviews, and 18 exit interviews were conducted. While support for local child immunisation programmes exists, limited understanding about vaccines and what they do was evident among younger and older people, particularly men. In general, parents and caregivers weigh several factors - such as personal opportunity costs, resource constraints, and perceived benefits - when deciding whether or not to have their children vaccinated, and the decision often is influenced by a network of people, including community leaders and health workers. The study raises issues that should inform a communications strategy and guide policy decisions within Kenya on eventual malaria vaccine introduction. Unlike the current practice, where health education on child welfare and immunisation focuses on women, the communications strategy should equally target men and women in ways that are appropriate for each gender, the authors argue. It should involve influential community members and provide needed information and reassurances about immunisation. Efforts also should be made to address concerns about the quality of immunisation services, including health workers' interpersonal communication skills.
The authors of this study set out to define the patient population at Cape Town’s district-level hospital offering specialist tuberculosis (TB) services, concerning the noted increase in complex, sick HIV-TB co-infected patients requiring increased levels of care. They surveyed all hospitalised adult patients in Brooklyn Chest Hospital, a district-level hospital offering specialist TB services, from 27-30 October 2008. They found that more than two-thirds of patients in the acute wards were HIV-co-infected, of whom 98% had significant co-morbidities and 60% had a Karnofsky performance score ≤30. Twenty-eight per cent of patients did not have a confirmed diagnosis of TB. In contrast, long-stay patients with multi-drug-resistant (MDR), pre-extensively (pre-XDR) and extensively drug-resistant (XDR) TB had a lower prevalence of HIV co-infection, but manifested high rates of co-morbidity. Overall, one-fifth of patients required up-referral to higher levels of care. In conclusion, the authors note that district-level hospitals, such as Brooklyn Chest Hospital, that offer specialist TB services share the increasing burden of complex, sick, largely HIV-co-infected TB patients with their secondary and tertiary level counterparts. To support these hospitals effectively, outreach, skills transfer through training, and improved radiology resources are required, they argue.
Although HIV and tuberculosis (TB) prevalence are high in prisons throughout sub-Saharan Africa, little research has been conducted on factors related to prevention, testing and treatment services. To better understand the relationship between prison conditions, the criminal justice system, and HIV and TB in Zambian prisons, the study conducted a mixed-method study, including: facility assessments and in-depth interviews with 246 prisoners and 30 prison officers at six Zambian prisons; a review of Zambian legislation and policy governing prisons and the criminal justice system; and 46 key informant interviews with government and non-governmental organization officials and representatives of international agencies and donors. The study found serious barriers to HIV and TB prevention and treatment, and extended pre-trial detention that contributed to overcrowded conditions. Disparities both between prisons and among different categories of prisoners within prisons were noted, with juveniles, women, pre-trial detainees and immigration detainees significantly less likely to access health services. The authors argue that current conditions and the lack of available medical care in Zambia's prisons violate human rights protections and threaten prisoners' health, and that prison-based health services should make linkages to community-based health care, and address general prison conditions and failures of the criminal justice system that exacerbate overcrowding.