Public Health: An action guide to improving health (2nd Edition)
John Walley and John Wright
Oxford University Press (14 January 2010)
Abstract: This Second Edition contains real examples, illustrations and case histories to bring an important subject to life for the reader. The book covers the essential clinical services and preventive programmes including those for TB, HIV/AIDS, malaria, diarrhoeal diseases and the integrated management of childhood and adult illnesses. Practical methods are given for assessing health needs and working with communities to develop health services, and the development of hospital, health centre, and community health services, particularly mother, neonatal and child health services are explained. Additionally gender, social and economic influences on communities' health are explored.
The clear language that is used throughout the book to describe the key public health skills (such as epidemiology, managing medicines, communicable and non communicable disease control, health financing, and implementing health services and programmes), will be accessible and highly valuable to doctors, community nurses, and other health professionals, whether in training or in practice as health officers and mangers of health services and programmes.
Cost implications of delays to tuberculosis diagnosis among pulmonary tuberculosis patients in Ethiopia
Mengiste M Mesefin, James Newell, Richard J Maddeley, Tolib N Mirzoev, Israel G Tareke, Yohannes T Kifle, Ammanuel Gessessew, John Walley
BMC Public Health 2010, 10: 173
10.1186/1471-2458-10-173
Background: Delays seeking care worsen the burden of tuberculosis and cost of care for patients, families and the public health system. This study investigates costs of tuberculosis diagnosis incurred by patients, escorts and the public health system in 10 districts of Ethiopia.
Methods: New pulmonary tuberculosis patients ≥ 15 years old were interviewed regarding their health care seeking behaviour at the time of diagnosis. Using a structured questionnaire patients were interviewed about the duration of delay at alternative care providers and the public health system prior to diagnosis. Costs incurred by patients, escorts and the public health system were quantified through patient interview and review of medical records.
Results: Interviews were held with 537 (58%) smear positive patients and 387 (42%) smear negative pulmonary patients. Of these, 413 (45%) were female; 451 (49%) were rural residents; and the median age was 34 years. The mean (median) days elapsed for consultation at alternative care providers and public health facilities prior to tuberculosis diagnosis was 5 days (0 days) and 3 (3 days) respectively. The total median cost incurred from first consultation to diagnosis was $27 per patient (mean = $59). The median costs per patient incurred by patient, escort and the public health system were $16 (mean = $29), $3 (mean = $23) and $3 (mean = $7) respectively. The total cost per patient diagnosed was higher for women, rural residents; those who received government food for work support, patients with smear negative pulmonary tuberculosis and patients who were not screened for TB in at least one district diagnostic centers.
Conclusions: The costs of tuberculosis diagnosis incurred by patients and escorts represent a significant portion of their monthly income. The costs arising from time lost in seeking care comprised a major portion of the total cost of diagnosis, and may worsen the economic position of patients and their families. Getting treatment from alternative sources and low index of suspicion public health providers were key problems contributing to increased cost of tuberculosis diagnosis. Thus, the institution of effective systems of referral, ensuring screening of suspects across the district public health system and the involvement of alternative care providers in district tuberculosis control can reduce delays and the financial burden to patients and escorts.
Background: Ethiopia is among countries with a high burden of tuberculosis (TB). The annual incidence of smear positive pulmonary TB is still high (163 per 100,000 population) despite the implementation of Directly Observed Treatment Short course strategy (DOTS) over the past two decades. This could partly be attributed to delays to TB treatment. Delay in TB diagnosis increases the risk of transmission and economic costs to patients and communities at large. The median patient delay at any public health facility is alarmingly prolonged with studies reporting from 2 to 4 months. In Ethiopia, delays arising from the use of alternative care providers (traditional healers, private practitioners and private pharmacies) and in public health facilities constitute about 24% of the total delay ]. Prolonged delays in accessing TB treatment have cost implications to patients, their families and the public health system]. Poverty is common among TB patients that may hinder their decision to seek early treatment]. Ethiopia is among the poorest countries in sub-Sahara where 65% of the population earns less than 1$ (United States Dollar) a day . Increases in patient cost could therefore lead to further delays and inequity in accessing TB treatment]. Nevertheless, the significance of the costs incurred by patients, escorts and the public health system has never been investigated in Ethiopia.
We have recently reported our investigation about the pattern of care seeking behaviour and risk factors for delays to seek care in public health facilities among pulmonary TB patients. Prolonged delay has been associated with female gender, rural poverty and illiteracy in that study. The evaluation of financial burdens encountered by patients in accessing TB care and their escorts is paramount for instituting measures for effective TB control. Here, we report the costs encountered to seek care among these patients prior to TB diagnosis. The study takes a societal perspective for evaluating these costs. The causes of delays at care providers and their cost implications were assessed in order to identify measures to reduce delays and costs of TB diagnosis within the ongoing TB control strategy.
An intervention to stop smoking among patients suspected of TB - evaluation of an integrated approach.
Siddiqi K, Khan A, Ahmad M, Shafiq-ur-Rehman.
BMC Public Health 10 Art. No. 160 25 Mar 2010
10.1186/2F1471-2458-10-160
Background: In many low- and middle-income countries, where tobacco use is common, tuberculosis is also a major problem. Tobacco use increases the risk of developing tuberculosis, secondary mortality, poor treatment compliance and relapses. In countries with TB epidemic, even a modest relative risk leads to a significant attributable risk. Treating tobacco dependence, therefore, is likely to have benefits for controlling tuberculosis in addition to reducing the non-communicable disease burden associated with smoking. In poorly resourced health systems which face a dual burden of disease secondary to tuberculosis and tobacco, an integrated approach to tackle tobacco dependence in TB control could be economically desirable. During TB screening, health professionals come across large numbers of patients with respiratory symptoms, a significant proportion of which are likely to be tobacco users. These clinical encounters, considered to be "teachable moments", provide a window of opportunity to offer treatment for tobacco dependence.
Methods/Design: We aim to develop and trial a complex intervention to reduce tobacco dependence among TB suspects based on the WHO 'five steps to quit' model. This model relies on assessing personal motivation to quit tobacco use and uses it as the basis for assessing suitability for the different therapeutic options for tobacco dependence.
We will use the Medical Research Council framework approach for evaluating complex interventions to: (a) design an evidence-based treatment package (likely to consist of training materials for health professionals and education tools for patients); (b) pilot the package to determine the delivery modalities in TB programme (c) assess the incremental cost-effectiveness of the package compared to usual care using a cluster RCT design; (d) to determine barriers and drivers to the provision of treatment of tobacco dependence within TB programmes; and (e) support long term implementation. The main outcomes to assess the effectiveness would be point abstinence at 4 weeks and continuous abstinence up to 6 months.
Discussion: This work will be carried out in Pakistan and is expected to have relevance for other low and middle income countries with high tobacco use and TB incidence. This will enhance our knowledge of the cost-effectiveness of treating tobacco dependence in patients suspected of TB.
Trial Registration Number: ISRCTN08829879
Getting NICE guidelines into practice: can e-learning help?
Walsh K; Sandars J; Kapoor S; Siddiqi K.
Clinical Governance: an International Journal. 2010; 15: 1 pp6-11
10.1108/14777271011017329
Purpose: The aim of this paper is to assess the impact of e-learning resources based on NICE guidelines in improving knowledge and changing practice among health professionals.
Design/methodology/approach: NICE in collaboration with BMJ Learning developed a series of e-learning modules based on NICE recommendations relating to osteoarthritis, irritable bowel syndrome, urinary tract infection in children, and antibiotic prophylaxis against infective endocarditis. The impact of these modules was evaluated by looking at the knowledge and skills of the learners before and after they did the modules and also asking the learners about resultant practice change.
Findings: A total of 5,116 users completed the modules. Completing them enabled users to increase their knowledge and skills score from the pre-test to the post-test by a statistically significant amount (p < 0.001): from a mean of 65 per cent to 85 per cent. Qualitative feedback to the modules was overwhelmingly positive. To test long-term effectiveness, users were e-mailed six weeks after they had completed the modules to assess practice change. The response rate to the survey was 22.2 per cent. In total 88.6 per cent of those who had cared for patients with these problems since completing the module said that it had helped them put NICE guidelines into practice.
Research limitations/implications : E-learning modules have high uptake, are popular and effective at helping health professionals learn about NICE guidelines and help them to put these guidelines into practice.
Originality/value: The study is valuable as it shows how interactive and multimedia resources help health professionals learn about guidelines. No previous studies have been identified.
An undergraduate education package on evidence based medicine: some NICE lessons.
Sandars J, Siddiqi K, Walsh K, Richardson J, Ibison J, M Maxted
Medical Education. 2010 44: 511-512
: 10.1111/j.1365-2923.2010.03675.x
Context: A recent survey carried out by the Centre for Evidence-Based Medicine highlighted the finding that education on evidence-based medicine (EBM) in UK medical schools was patchy and mainly focused on literature searches and critical appraisal skills (personal communication). The National Institute for Health and Clinical Excellence (NICE) considered that there was a need for a learning package that focused on the practical application of EBM in terms of putting the evidence into practice.
Why the idea was necessary: NICE recently identified a potential gap in the undergraduate medical curriculum with regard to EBM and proposed an e-learning package that was developed in collaboration with BMJ Learning and Leeds and St George’s Medical Schools.
What was done: The package consisted of four modules covering the following topics: (i) evidence-based decision making; (ii) following evidence-based guidance; (iii) audit and feedback, and (iv) changing practice. The modules used a variety of online methods, including text, images, videos and interactivity through self-assessment questions and feedback. The learning package was piloted at the two medical schools with the intention of integrating the package into the curriculum of final-year students. An independent evaluation was carried out to determine its feasibility, effectiveness, usefulness and usability. Students completing these modules were asked to provide online free text feedback at the end of each module. In addition, these final-year students were invited to complete a semi-structured questionnaire and a focus group interview was carried out at each medical school.
Evaluation of results:A total of 215 modules were completed. Overall, 165 comments were left by students who used the package: 103 comments were positive, 32 neutral and 30 negative. For the majority of students, the modules provided a good overview or clarification of issues already covered in their courses. Several students found this a good resource of new material. Students also, on the whole, appeared to like the structure of the modules and the interactivity of the platform. On the negative side, some users found the questions too easy, repetitive and imbalanced. In response to the questionnaire, the majority commented that the modules were easy to access and navigate. Students also liked the repeated self-tests in the modules. Most stated that the modules increased their understanding of EBM and NICE guidelines. In the focus groups students generally confirmed that they had found the modules useful. Some commented that they would have preferred the modules to have been available during the earlier years of their training when they had more time and were less focused on final examinations and preparations for foundation training.
.Following this pilot, we plan to make these modules freely available to medical students (regardless of their year of study) in other medical schools, as well as to foundation year doctors and other health care professionals and to encourage schools to integrate the package into their curricula if they wish to.
Knowledge and reported practices of men and women on maternal and child health in rural Guinea Bissau: a cross sectional survey.
King, R., V. Mann and P.D. Boone.
BMC Public Health 2010, 10:319
10.1186/1471-2458-10-319
Background: Participatory health education interventions and/or community-based primary health care in remote regions can improve child survival. The most recent data from Guinea Bissau shows that the country ranks 5th from bottom globally with an under-five mortality rate of 198 per 1000 live births in 2007. EPICS (Enabling Parents to Increase Child Survival) is a cluster randomised trial, which is currently running in rural areas of southern Guinea Bissau. It aims to evaluate whether an intervention package can generate a rapid and cost-effective reduction in under-five child mortality. The purpose of the study described here was to understand levels of knowledge on child health and treatment-seeking and preventative behaviours in southern Guinea Bissau in order to develop an effective health education component for the EPICS trial. The study also aimed to assess the effect of gender and ethnicity on knowledge and behaviour.
Methods: Women and men were interviewed in their households using a structured questionnaire. Characteristics of the households and of the interviewed women and men were tabulated. The number of correct answers given to the health knowledge and practice questions and their percentage distribution were tabulated by items and by gender. An overall health knowledge score was derived.
Results: There are low levels of appropriate knowledge on child health, some inappropriate practices and generally low vaccination coverage. Health knowledge scores improve significantly amongst those who have accessed higher education. Differences in health knowledge between women and men become insignificant once age and education are accounted for.
Conclusions: Health education activities should be an integral part of a package to improve child survival in rural Guinea Bissau. These activities should focus on diarrhoea, malaria, pneumonia, pregnancy, delivery, neonatal care and vaccination coverage, as these are areas where knowledge and practices were found to be inadequate in this study. Men as well as women should be involved in these activities. Prior to developing health education interventions in similar settings, studies to assess areas to be targeted should be conducted.
The EPICS Trial: Enabling Parents to Increase Child Survival through the introduction of community-based health interventions in rural Guinea Bissau.
Mann, V., I. Fazzio, R. King. et al..
BMC Public Health 2009, 9:279
10.1186/1471-2458-9-279
Background: Guinea-Bissau is a small country in West Africa with a population of 1.7 million. The WHO and UNICEF reported an under-five child mortality of 203 per 1000, the 10th highest amongst 192 countries. The aim of the trial is to assess whether an intervention package that includes community health promotion campaign and education through health clubs, intensive training and mentoring of village health workers to diagnose and provide first-line treatment for children's diseases within the community, and improved outreach services can generate a rapid and cost-effective reduction in under-five child mortality in rural regions of Guinea-Bissau. Effective Intervention plans to expand the project to a much larger region if there is good evidence after two and a half years that the project is generating a cost-effective, sustainable reduction in child mortality.
Methods/design: This trial is a cluster-randomised controlled trial involving 146 clusters. The trial will run for 2.5 years. The interventions will be introduced in two stages: seventy-three clusters will receive the interventions at the start of the project, and seventy-three control clusters will receive the interventions 2.5 years after the first clusters have received all interventions if the research shows that the interventions are effective. The impact of the interventions and cost-effectiveness will be measured during the first stage.
The package of interventions includes a community health promotion campaign and education through health clubs, and intensive training and mentoring of village health workers to diagnose and provide first-line treatment for common children's diseases within the community. It also includes improved outreach services to encourage provision of antenatal and post natal care and provide ongoing monitoring for village health workers.
The primary outcome of the trial will be the proportion of children that die under 5 years of age during the trial. Secondary outcomes will include age at and cause of child deaths, neonatal mortality, infant mortality, maternal mortality, health knowledge, health seeking behaviour, morbidity and costs.
Discussion: The trial will be run by research and service delivery teams that act independently, overseen by a trial steering committee. A data monitoring committee will be appointed to monitor the outcome and any adverse effects.
Trial Registration: Current Controlled Trials ISRCTN52433336
‘Smoke Free Homes’: An intervention to reduce second-hand smoke exposure in households.
INT J TUBERC LUNG D, October 2010
I Cameron, K Siddiqi, R Sarmad, RA Usmani, A Kanwal, H Thomson
Abstract:
BACKGROUND: Second-hand tobacco smoke is a serious health hazard. We tested the fidelity and feasibility of the Smoke-Free Homes (SFH) intervention and looked for preliminary evidence of its effectiveness in imposing smoking restrictions in homes in Pakistan. METHODS: SFH was piloted and adapted for Pakistan. The adapted SFH intervention was then delivered to primary schoolchildren, community leaders and health professionals in a semi-rural Union Council. We carried out a survey before and after the intervention to assess adult smoking behaviour and restrictions at homes. We also carried out focus group discussions with stakeholders to determine the appropriateness and acceptability of the intervention. RESULTS: We found the adapted SFH intervention feasible and appropriate in a typical semi-rural setting in Pakistan. The proportion of smoke-free homes increased from 43% (95%CI 37.4-48.2) to 85% (95%CI 80.9-89.2) after the intervention. The number of households with at least one smoker decreased from 57.5% (95%CI 52.1-62.9) to 38.4% (95%CI 32.7-44.1). There was a reduction in self-reported adult smoking prevalence from 44% (95%CI 39-48) to 28% (95%CI 24-33) in males. CONCLUSION: SFH has the potential to influence adult smoking behaviour in households. This approach needs to be further evaluated to establish its effectiveness and cost-effectiveness and to ascertain its long-term sustainability.
Status-Disclosure among HIV-Positive Women: An Insight into the Role of HIV/Aids Support Groups in Rural Kenya African
Journal for Aids Research (2010) 9 (4).
Gillet, H. J. and J. Parr
Abstract
Disclosure by people living with HIV or AIDS is critical for HIV prevention and care. However, many women choose not to disclose their HIV status for fear of negative outcomes, such as blame and rejection. The World Health Organization suggests that HIV/AIDS support groups help to encourage women to disclose their status, but little is known about the role of such groups in Kenya. This study used qualitative research methods to gain insight into rural women’s experience of disclosing a positive HIV status and it explores opinions about the role of support groups in relation to disclosure. Focus group discussions and semi-structured interviews were conducted with HIV/AIDS support group members and leaders. Thematic analysis showed that the women felt a sense of duty to inform others of their HIV status, particularly in order to prevent HIV transmission and to encourage sexual partners to be tested. There were multiple problems associated with disclosure, and negative outcomes such as blame and rejection were common. Support groups gave the women confidence and provided emotional support, which may have assisted them with coping with the negative outcomes of disclosure. The findings demonstrate that such support may improve women’s experience of HIV-status disclosure and possibly even promote disclosure. However, initiatives such as these must protect those who disclose and therefore should take into account the local cultural and economic context.