Contribution of the Community Health Volunteers in the Control of Buruli Ulcer in Bénin

Background

Buruli ulcer (BU) is a neglected tropical disease caused by Mycobacterium ulcerans. Usually BU begins as a painless nodule, plaque or edema, ultimately developing into an ulcer. The high number of patients presenting with ulcers in an advanced stage is striking. Such late presentation will complicate treatment and have long-term disabilities as a consequence. The disease is mainly endemic in West Africa. The primary strategy for control of this disease is early detection using community village volunteers.

Methodology/Principal Findings

In this retrospective, observational study, information regarding Buruli ulcer patients that reported to one of the four BU centers in Bénin between January 2008 and December 2010 was collected using the WHO/BU01 forms. Information used from these forms included general characteristics of the patient, the results of diagnostic tests, the presence of functional limitations at start of treatment, lesion size, patient delay and the referral system. The role of the different referral systems on the stage of disease at presentation in the hospital was analyzed by a logistic regression analysis. About a quarter of the patients (26.5%) were referred to the hospital by the community health volunteers. In our data set, patients referred to the hospital by community health volunteers appeared to be in an earlier stage of disease than patients referred by other methods, but after adjustment by the regression analysis for the health center, this effect could no longer be seen. The Polymerase Chain Reaction (PCR) for IS2404 positivity rate among patients referred by the community health volunteers was not systematically lower than in patients referred by other systems.

Conclusions/Significance

This study clarifies the role played by community health volunteers in Bénin, and shows that they play an important role in the control of BU.     

What Are the Roles and Responsibilities of the Media in Disseminating Health Information?

BACKGROUND TO THE DEBATE: In December 2004 three news stories in the popular press suggested that the side effects of single-dose nevirapine, which has been proven to prevent mother-to-child transmission of HIV, had been covered up. Many HIV experts believed that the stories were unwarranted and that they would undermine use of the drug, leading to a rise in neonatal HIV infection. The controversy surrounding these stories prompted the PLoS Medicine editors to ask health journalists, and others with an interest in media reporting of health, to share their views on the roles and responsibilities of the media in disseminating health information.     

Has the Rajiv Aarogyasri Community Health Insurance Scheme of Andhra Pradesh Addressed the Educational Divide in Accessing Health Care?

Background

Equity of access to healthcare remains a major challenge with families continuing to face financial and non-financial barriers to services. Lack of education has been shown to be a key risk factor for ''catastrophic'' health expenditure (CHE), in many countries including India. Consequently, ways to address the education divide need to be explored. We aimed to assess whether the innovative state-funded Rajiv Aarogyasri Community Health Insurance Scheme of Andhra Pradesh state launched in 2007, has achieved equity of access to hospital inpatient care among households with varying levels of education.

Methods

We used the National Sample Survey Organization 2004 survey as our baseline and the same survey design to collect post-intervention data from 8623 households in the state in 2012. Two outcomes, hospitalisation and CHE for inpatient care, were estimated using education as a measure of socio-economic status and transforming levels of education into ridit scores. We derived relative indices of inequality by regressing the outcome measures on education, transformed as a ridit score, using logistic regression models with appropriate weights and accounting for the complex survey design.

Findings

Between 2004 and 2012, there was a 39% reduction in the likelihood of the most educated person being hospitalised compared to the least educated, with reductions observed in all households as well as those that had used the Aarogyasri. For CHE the inequality disappeared in 2012 in both groups. Sub-group analyses by economic status, social groups and rural-urban residence showed a decrease in relative indices of inequality in most groups. Nevertheless, inequalities in hospitalisation and CHE persisted across most groups.

Conclusion

During the time of the Aarogyasri scheme implementation inequalities in access to hospital care were substantially reduced but not eliminated across the education divide. Universal access to education and schemes such as Aarogyasri have the synergistic potential to achieve equity of access to healthcare.     

Understanding Inequalities in Child Health in Ethiopia: Health Achievements Are Improving in the Period 2000–2011

Objective

In Ethiopia, coverage of key health services is low, and community based services have been implemented to improve access to key services. This study aims to describe and assess the level and the distribution of health outcomes and coverage for key services in Ethiopia, and their association with socioeconomic and geographic determinants.

Methods

Data were obtained from the 2000, 2005 and 2011 Ethiopian Demographic and Health Surveys. As indicators of access to health care, the following variables were included: Under-five and neonatal deaths, skilled birth attendance, coverage of vaccinations, oral rehydration therapy for diarrhoea, and antibiotics for suspected pneumonia. For each of the indicators in 2011, inequality was described by estimating their concentration index and a geographic Gini index. For further assessment of the inequalities, the concentration indices were decomposed. An index of health achievement, integrating mean coverage and the distribution of coverage, was estimated. Changes from 2000 to 2011 in coverage, inequality and health achievement were assessed.

Results

Significant pro-rich inequalities were found for all indicators except treatment for suspected pneumonia in 2011. The geographic Gini index showed significant regional inequality for most indicators. The decomposition of the 2011 concentration indices revealed that the factor contributing the most to the observed inequalities was different levels of wealth. The mean of all indicators improved from 2000 to 2011, and the health achievement index improved for most indicators. The socioeconomic inequalities seem to increase from 2000 to 2011 for under-five and neonatal deaths, whereas they are stable or decreasing for the other indicators.

Conclusion

There is an unequal socioeconomic and geographic distribution of health and access to key services in Ethiopia. Although the health achievement indices improved for most indicators from 2000 to 2011, socioeconomic determinants need to be addressed in order to achieve better and more fairly distributed health.     

Understanding the Role of Accredited Drug Dispensing Outlets in Tanzania’s Health System

IntroductionPeople in many low-income countries access medicines from retail drug shops. In Tanzania, a public-private partnership launched in 2003 used an accreditation approach to improve access to quality medicines and pharmaceutical services in underserved areas. The government scaled up the accredited drug dispensing outlet (ADDO) program nationally, with over 9,000 shops now accredited. This study assessed the relationships between community members and their sources of health care and medicines, particularly antimicrobials, with a specific focus on the role ADDOs play in the health care system.MethodsUsing mixed methods, we collected data in four regions. We surveyed 1,185 households and audited 96 ADDOs and 84 public/nongovernmental health facilities using a list of 17 tracer drugs. To determine practices in health facilities, we interviewed 1,365 exiting patients. To assess dispensing practices, mystery shoppers visited 306 ADDOs presenting one of three scenarios (102 each) about a child’s respiratory symptoms.ConclusionADDOs are the principal source of medicines in Tanzania and an important part of a multi-faceted health care system. Poor prescribing in health facilities, poor dispensing at ADDOs, and inappropriate patient demand continue to contribute to inappropriate medicines use. Therefore, while accreditation has attempted to address the quality of pharmaceutical services in private sector drug outlets, efforts to improve access to and use of medicines in Tanzania need to target ADDOs, public/nongovernmental health facilities, and the public to be effective.     

Hospital Expenditure at the End-of-Life: What Are the Impacts of Health Status and Health Risks?

Background

It is important for health policy and expenditure projections to understand the relationship between age, death and expenditure on health care (HC). Research has shown that older age groups incur lower hospital costs than previously anticipated and that remaining time to death (TTD) was a much stronger indicator for expenditure than age. How health behaviour or risk factors impact on HC utilisation and costs at the end of life is relatively unknown. Smoking and Body Mass Index (BMI) have featured most prominently and mixed findings exist as to the exact nature of this association.

Methods

This paper considers the relationship between TTD, age and expenditure for inpatient care in the last 12 quarters of life; and introduces measures of health status and risks. A longitudinal dataset covering 35 years is utilised, including baseline survey data linked to hospital and death records. The effect of age, TTD and health indicators on expenditure for inpatient care is estimated using a two-part model.

Results

As individuals approach death costs increase. This effect is highly significant (p<0.01) from the last until the 8th quarter before death and influenced by age. Statistically significant effects on costs were found for: smoking status, systolic blood pressure and lung function (FEV1). On average, smokers incurred lower quarterly costs in their last 12 quarters of life than non-smokers (~7%). Participants’ BMI at baseline did show a negative association with probability of HC utilisation however this effect disappeared when costs were estimated.

Conclusions

Health risk measures obtained at baseline provide a good indication of individuals’ probability of needing medical attention later in life and incurring costs, despite the small size of the effect. Utilising a linked dataset, where such measures are available can add substantially to our ability to explain the relationship between TTD and costs.     

Longitudinal Predictors of Functional Impairment in Older Adults in Europe – Evidence from the Survey of Health,Ageing and Retirement in Europe

Objective

To examine time-dependent predictors of functional impairment in older adults in Europe longitudinally.

Methods

Data were derived from the Survey of Health Ageing, and Retirement in Europe (2004–2013). Functional impairment was assessed by using activities of daily living (ADL) and instrumental activities of daily living (IADL) indices. Fixed effects regressions were used to estimate the effects of sociodemographic factors (age, marital status, living situation, and income deciles (median split)), lifestyle factors (smoking status and alcohol consumption per week), depression, cognitive function and chronic diseases on the outcome variables.

Results

Longitudinal regressions revealed that functional impairment increased significantly with age, the occurrence of depression, cognitive impairment, the number of chronic conditions, and less than daily alcohol consumption in the total sample and in both sexes. Moreover, the onset of smoking and living without a spouse/partner in household increased functional impairment in the total sample. The effect of depression on functional impairment was significantly more pronounced in men.

Conclusion

Our findings highlight the relevance of changes in age, depression, cognitive function, smoking and chronic diseases for functional impairment. Since particularly depression and smoking may be avoidable, developing strategies to prevent depression or stop smoking might be useful approaches to postpone functional impairment in older adults.     

Can Plan Recommendations Improve the Coverage Decisions of Vulnerable Populations in Health Insurance Marketplaces?

Objective

The Affordable Care Act’s marketplaces present an important opportunity for expanding coverage but consumers face enormous challenges in navigating through enrollment and re-enrollment. We tested the effectiveness of a behaviorally informed policy tool—plan recommendations—in improving marketplace decisions.

Study Setting

Data were gathered from a community sample of 656 lower-income, minority, rural residents of Virginia.

Study Design

We conducted an incentive-compatible, computer-based experiment using a hypothetical marketplace like the one consumers face in the federally-facilitated marketplaces, and examined their decision quality. Participants were randomly assigned to a control condition or three types of plan recommendations: social normative, physician, and government. For participants randomized to a plan recommendation condition, the plan that maximized expected earnings, and minimized total expected annual health care costs, was recommended.

Data Collection

Primary data were gathered using an online choice experiment and questionnaire.

Principal Findings

Plan recommendations resulted in a 21 percentage point increase in the probability of choosing the earnings maximizing plan, after controlling for participant characteristics. Two conditions, government or providers recommending the lowest cost plan, resulted in plan choices that lowered annual costs compared to marketplaces where no recommendations were made.

Conclusions

As millions of adults grapple with choosing plans in marketplaces and whether to switch plans during open enrollment, it is time to consider marketplace redesigns and leverage insights from the behavioral sciences to facilitate consumers’ decisions.     

Climate Change-related Health Impacts in the Hindu Kush–Himalayas

Our goal was to identify the climate change-related health risks and vulnerable populations specific to the mountainous regions of the Hindu Kush–Himalayas. We reviewed published information of the likely health consequences of climate change in mountain regions, especially the findings of a workshop for countries in the Hindu Kush–Himalaya region, organized by the World Health Organization, World Meteorological Organization, United Nations Environment Programme, and United Nations Development Programme. The main climate-related risks in the Hindu Kush–Himalaya region include the expansion of vector-borne diseases as pathogens take advantage of new habitats in altitudes that were formerly unsuitable. Diarrheal diseases could become more prevalent with changes in freshwater quality and availability. More extreme rainfall events are likely to increase the number of floods and landslides with consequent death and injuries. A unique risk is sudden floods from high glacier lakes, which cause substantial destruction and loss of life. Because glaciers are the main source of freshwater for upland regions and downstream countries, the long-term reduction in annual glacier snowmelt is expected to heighten existing water insecurity in these areas. Climate change also is bringing some benefits to mountain populations, including milder winters and longer growing seasons. Populations in mountain regions have unique combinations of vulnerabilities to climate change. The extent of the health impacts experienced will depend on the effectiveness of public health efforts to identify and implement low-cost preparedness and response measures, and on the speed at which emissions of greenhouse gas emissions can be reduced.     

Use of Systems Biology Approaches to Analysis of Genome-Wide Association Studies of Myocardial Infarction and Blood Cholesterol in the Nurses' Health Study and Health Professionals’ Follow-Up Study

With the advance of genome-wide association studies and newly identified SNP (single-nucleotide polymorphism) associations with complex disease, important discoveries have emerged focusing not only on individual genes but on disease-associated pathways and gene sets. The authors used prospective myocardial infarction case-control studies nested in the Nurses’ Health and Health Professionals Follow-Up Studies to investigate genetic variants associated with myocardial infarction or LDL, HDL, triglycerides, adiponectin and apolipoprotein B (apoB). Using these case-control studies to illustrate an integrative systems biology approach, the authors applied SNP set enrichment analysis to identify gene sets where expression SNPs representing genes from these sets show enrichment in their association with endpoints of interest. The authors also explored an aggregate score approach. While power limited one’s ability to detect significance for association of individual loci with myocardial infarction, the authors found significance for loci associated with LDL, HDL, apoB and triglycerides, replicating previous observations. Applying SNP set enrichment analysis and risk score methods, the authors also found significance for three gene sets and for aggregate scores associated with myocardial infarction as well as for loci-related to cardiovascular risk factors, supporting the use of these methods in practice.     

A Perspective on the History and Evolution of an Oceans and Human Health “Metadiscipline” in the USA

We review recent history and evolution of Oceans and Human Health programs and related activities in the USA from a perspective within the Federal government. As a result of about a decade of support by the US Congress and through a few Federal agencies, notably the National Science Foundation, National Institute of Environmental Health Sciences, and National Ocean and Atmospheric Administration, robust Oceans and Human Health (OHH) research and application activities are now relatively widespread, although still small, in a number of agencies and academic institutions. OHH themes and issues have been incorporated into comprehensive federal ocean research plans and are reflected in the new National Ocean Policy enunciated by Executive Order 13547. In just a decade, OHH has matured into a recognized “metadiscipline,” with development of a small, but robust and diverse community of science and practice, incorporation into academic educational programs, regular participation in ocean and coastal science and public health societies, and active engagement with public health decision makers. In addition to substantial increases in scientific information, the OHH community has demonstrated ability to respond rapidly and effectively to emergency situations such as those associated with extreme weather events (e.g., hurricanes, floods) and human-caused disasters (e.g., the Deep Water Horizon oil spill). Among many other things, next steps include development and implementation of agency health strategies and provision of specific services, such as ecological forecasts to provide routine early warnings for ocean health threats and opportunities for prevention and mitigation of these risks.     

Benefits in Cash or in Kind? A Community Consultation on Types of Benefits in Health Research on the Kenyan Coast

BackgroundProviding benefits and payments to participants in health research, either in cash or in kind, is a common but ethically controversial practice. While much literature has concentrated on appropriate levels of benefits or payments, this paper focuses on less well explored ethical issues around the nature of study benefits, drawing on views of community members living close to an international health research centre in Kenya.MethodsThe consultation, including 90 residents purposively chosen to reflect diversity, used a two-stage deliberative process. Five half-day workshops were each followed by between two and four small group discussions, within a two week period (total 16 groups). During workshops and small groups, facilitators used participatory methods to share information, and promote reflection and debate on ethical issues around types of benefits, including cash, goods, medical and community benefits. Data from workshop and field notes, and voice recordings of small group discussions, were managed using Nvivo 10 and analysed using a Framework Analysis approach.

Findings and Conclusions

The methods generated in-depth discussion with high levels of engagement. Particularly for the most-poor, under-compensation of time in research carries risks of serious harm. Cash payments may best support compensation of costs experienced; while highly valued, goods and medical benefits may be more appropriate as an ‘appreciation’ or incentive for participation. Community benefits were seen as important in supporting but not replacing individual-level benefits, and in building trust in researcher-community relations. Cash payments were seen to have higher risks of undue inducement, commercialising relationships and generating family conflicts than other benefits, particularly where payments are high. Researchers should consider and account for burdens families may experience when children are involved in research. Careful context-specific research planning and skilled and consistent communication about study benefits and payments are important, including in mitigating potential negative effects.     

Environment--a new key area for Health of the Nation?

Later this month the government will be consulting on whether the environment should be adopted as a new key area for their Health of the Nation strategy. It is proposing to have five topic areas and to adopt 10-15 environmental targets. This would reaffirm its commitment to linking environmental policy and health policy following publication earlier this year of its environmental health action plan. Critics may respond to the consultation document with suggestions for more far reaching targets--based, for example, on the "Health for All" targets from the World Health Organisation, or those arising out of Agenda 21 from the earth summit in Rio De Janeiro. Whatever the criticism, this move will be a chance to link environmental and health agendas at both national and local level.     

MENTAL HEALTH PROGRAMS—The Role of the Health Officer

Traditionally the treatment of mental illness has been a responsibility of state governments, but they have been unable to solve the problem with any degree of success.In spite of rationalizations as to why a health department should not become involved in this field, more and more local health departments in California and across the nation are initiating various services in mental health.With the widespread interest in mental health at national and state levels and in local citizens'' groups, local health officers must involve themselves in this most difficult effort.While the treatment of the emotionally disturbed and the psychotic is demanded most aggressively by the public which seeks outpatient, inpatient, and rehabilitation services on the local level, two services—consultation and education-information services—offer more hope in the promotion of mental health as contrasted with the treatment of mental illness.     

Analyzing the Relationship between Objective–Subjective Health Status and Public Perception of Climate Change as a Human Health Risk in Coastal Tanzania

Climate change is considered as the biggest threat to human health in the 21st century. Sub-Saharan Africa, which is the most-at-risk region of the world, is estimated to have a disproportionately large share of the burden of climate change–induced environmental and human health risks. To develop effective adaptations to protect public health, it is essential to consider how individuals perceive and understand the risks, and how they might be willing to change their behaviors in response to them. Using a cross-sectional survey of 1253 individuals in coastal Tanzania we analyzed the relationship between subjective health status (self-reported health) and objective health status on the one hand and perceived health risks of climate change. Generally, higher subjective health status was associated with lower scores on perceived health risks of climate change. Concerning objective health status, the results were varied. Individuals who affirmed that they had been previously diagnosed with hepatitis, skin conditions, or tuberculosis had lower scores on perceived health risks of climate change, unlike their counterparts who affirmed that they had been previously diagnosed with malaria in the past 12 months or had been diagnosed with HIV/AIDS. These relationships persist even when biosocial and sociocultural attributes are taken into consideration. The results underscore the complex ways in which objective and subjective health interact with both biosocial and sociocultural factors to shape perceived health risks of climate change.