Health care as a right, fairness and medical resources

Our intention in the following is to use the WHO declaration as a basis for considering the allocation of resources in health care. We shall first argue that most of the criteria suggested as grounds for fair allocation of scarce medical resources have their difficulties if one tries to apply them one by one to medical practices. We shall then go on to claim that, if we take the right of all human beings to health or health care even moderately seriously, increasing the resources would in most cases be more ethical than attempting to allocate them 'fairly'.     

Beyond the Biomedical: Community Resources for Mental Health Care in Rural Ethiopia

BackgroundThe focus of discussion in addressing the treatment gap is often on biomedical services. However, community resources can benefit health service scale-up in resource-constrained settings. These assets can be captured systematically through resource mapping, a method used in social action research. Resource mapping can be informative in developing complex mental health interventions, particularly in settings with limited formal mental health resources.MethodWe employed resource mapping within the Programme for Improving Mental Health Care (PRIME), to systematically gather information on community assets that can support integration of mental healthcare into primary care in rural Ethiopia. A semi-structured instrument was administered to key informants. Community resources were identified for all 58 sub-districts of the study district. The potential utility of these resources for the provision of mental healthcare in the district was considered.ResultsThe district is rich in community resources: There are over 150 traditional healers, 164 churches and mosques, and 401 religious groups. There were on average 5 eddir groups (traditional funeral associations) per sub-district. Social associations and 51 micro-finance institutions were also identified. On average, two traditional bars were found in each sub-district. The eight health centres and 58 satellite clinics staffed by Health Extension Workers (HEWs) represented all the biomedical health services in the district. In addition the Health Development Army (HDA) are community volunteers who support health promotion and prevention activities.DiscussionThe plan for mental healthcare integration in this district was informed by the resource mapping. Community and religious leaders, HEWs, and HDA may have roles in awareness-raising, detection and referral of people with mental illness, improving access to medical care, supporting treatment adherence, and protecting human rights. The diversity of community structures will be used to support rehabilitation and social reintegration. Alcohol use was identified as a target disorder for community-level intervention.     

Medical housing "lines".

General practitioners are often asked for medical certificates (housing "lines") by applicants for council housing who claim to have medical problems requiring housing priority. The results of a survey by questionnaire showed that general practitioners in Edinburgh do not know how the housing system works and that they seem to overestimate their patients'' chances of obtaining suitable council housing. General practitioners need to know how the housing system works, and communication between general practitioners and housing departments should be improved. A comparison was also made between the number of medical points awarded by a community medicine specialist and a group of general practitioners who had written housing "lines" for their patients. The general practitioners tended to award more points than the specialist. Social priority for housing should be recognised as an independent factor and a new category of top social priority added.     

Reductions in Inpatient Mortality following Interventions to Improve Emergency Hospital Care in Freetown,Sierra Leone

Background

The demand for high quality hospital care for children in low resource countries is not being met. This paper describes a number of strategies to improve emergency care at a children''s hospital and evaluates the impact of these on inpatient mortality. In addition, the cost-effectiveness of improving emergency care is estimated.

Methods and Findings

A team of local and international staff developed a plan to improve emergency care for children arriving at The Ola During Children''s Hospital, Freetown, Sierra Leone. Following focus group discussions, five priority areas were identified to improve emergency care; staff training, hospital layout, staff allocation, medical equipment, and medical record keeping. A team of international volunteers worked with local staff for six months to design and implement improvements in these five priority areas. The improvements were evaluated collectively rather than individually. Before the intervention, the inpatient mortality rate was 12.4%. After the intervention this improved to 5.9%. The relative risk of dying was 47% (95% CI 0.369–0.607) lower after the intervention. The estimated number of lives saved in the first two months after the intervention was 103. The total cost of the intervention was USD 29 714, the estimated cost per death averted was USD 148. There are two main limitation of the study. Firstly, the brevity of the study and secondly, the assumed homogeneity of the clinical cases that presented to the hospital before and after the intervention.

Conclusions

This study demonstarted a signficant reductuion in inpatient mortality rate after an intervention to improve emergency hospital care If the findings of this paper could be reproduced in a larger more rigorous study, improving the quality of care in hospitals would be a very cost effective strategy to save children''s lives in low resource settings.     

Randomised comparison of the effectiveness and costs of community and hospital based mental health services for children with behavioural disorders

ObjectiveTo test the hypothesis that a community based intervention by secondary child and adolescent mental health services would be significantly more effective and less costly than a hospital based intervention.DesignOpen study with two randomised parallel groups.SettingTwo health districts in the north of England.ParticipantsParents of 3 to 10 year old children with behavioural disorder who had been referred to child and adolescent mental health services.InterventionParental education groups.Results141 subjects were randomised to community (n=72) or hospital (n=69) treatment. Primary outcome data were obtained on 115 (82%) cases a year later. Intention to treat analyses showed no significant differences between the community and hospital based groups on any of the outcome measures, or on costs. Parental depression was common and predicted the child''s outcome.ConclusionsLocation of child mental health services may be less important than the range of services that they provide, which should include effective treatment for parents'' mental health problems.     

A School Based Cluster Randomised Health Education Intervention Trial for Improving Knowledge and Attitudes Related to Taenia solium Cysticercosis and Taeniasis in Mbulu District,Northern Tanzania

Taenia solium causes significant economic and public health impacts in endemic countries. This study determined effectiveness of a health education intervention at improving school children’s knowledge and attitudes related to T. solium cysticercosis and taeniasis in Tanzania. A cluster randomised controlled health education intervention trial was conducted in 60 schools (30 primary, 30 secondary) in Mbulu district. Baseline data were collected using a structured questionnaire in the 60 schools and group discussions in three other schools. The 60 schools stratified by baseline knowledge were randomised to receive the intervention or serve as control. The health education consisted of an address by a trained teacher, a video show and a leaflet given to each pupil. Two post-intervention re-assessments (immediately and 6 months post-intervention) were conducted in all schools and the third (12 months post-intervention) was conducted in 28 secondary schools. Data were analysed using Bayesian hierarchical log-binomial models for individual knowledge and attitude questions and Bayesian hierarchical linear regression models for scores. The overall score (percentage of correct answers) improved by about 10% in all schools after 6 months, but was slightly lower among secondary schools. Monitoring alone was associated with improvement in scores by about 6%. The intervention was linked to improvements in knowledge regarding taeniasis, porcine cysticercosis, human cysticercosis, epilepsy, the attitude of condemning infected meat but it reduced the attitude of contacting a veterinarian if a pig was found to be infected with cysticercosis. Monitoring alone was linked to an improvement in how best to raise pigs. This study demonstrates the potential value of school children as targets for health messages to control T. solium cysticercosis and taeniasis in endemic areas. Studies are needed to assess effectiveness of message transmission from children to parents and the general community and their impacts in improving behaviours facilitating disease transmission.     

Can Volunteer Community Health Workers Decrease Child Morbidity and Mortality in Southwestern Uganda? An Impact Evaluation

Background

The potential for community health workers to improve child health in sub-Saharan Africa is not well understood. Healthy Child Uganda implemented a volunteer community health worker child health promotion model in rural Uganda. An impact evaluation was conducted to assess volunteer community health workers'' effect on child morbidity, mortality and to calculate volunteer retention.

Methodology/Principal Findings

Two volunteer community health workers were selected, trained and promoted child health in each of 116 villages (population ∼61,000) during 2006–2009. Evaluation included a household survey of mothers at baseline and post-intervention in intervention/control areas, retrospective reviews of community health worker birth/child death reports and post-intervention focus group discussions. Retention was calculated from administrative records. Main outcomes were prevalence of recent child illness/underweight status, community health worker reports of child deaths, focus group perception of effect, and community health worker retention. After 18–36 months, 86% of trained volunteers remained active. Post-intervention surveys in intervention households revealed absolute reductions of 10.2% [95%CI (−17.7%, −2.6%)] in diarrhea prevalence and 5.8% [95%CI (−11.5%, −0.003%)] in fever/malaria; comparative decreases in control households were not statistically significant. Underweight prevalence was reduced by 5.1% [95%CI (−10.7%, 0.4%)] in intervention households. Community health worker monthly reports revealed a relative decline of 53% in child deaths (<5 years old), during the first 18 months of intervention. Focus groups credited community health workers with decreasing child deaths, improved care-seeking practices, and new income-generating opportunities.

Conclusions/Significance

A low-cost child health promotion model using volunteer community health workers demonstrated decreased child morbidity, dramatic mortality trend declines and high volunteer retention. This sustainable model could be scaled-up to sub-Saharan African communities with limited resources and high child health needs.     

Economic and social structure for an ageing population.

The driving force behind the improvement in the quality of life, the rising standard of living, improving health, and increasing longevity, is a process called ''technophysio evolution'', which began about 300 years ago, accelerated during the twentieth century, and is still in progress. Increased spending on health care and on pensions is an appropriate concomitant of technophysio evolution, and should be welcomed. Only wasteful medical services should be restricted. The resources available now and in the future can provide increasingly long and healthy lives of relative luxury for all. However, methods of financing health care and retirement need to be modernized. In the future, luxury will be defined increasingly in terms of spiritual rather than material resources. The test of well-being in the future for both young and old will be measured increasingly in terms of the quality of health and the opportunity for self-realization.     

Exercise therapy for prevention of falls in people with Parkinson's disease: A protocol for a randomised controlled trial and economic evaluation

Background

People with Parkinson's disease are twice as likely to be recurrent fallers compared to other older people. As these falls have devastating consequences, there is an urgent need to identify and test innovative interventions with the potential to reduce falls in people with Parkinson's disease. The main objective of this randomised controlled trial is to determine whether fall rates can be reduced in people with Parkinson's disease using exercise targeting three potentially remediable risk factors for falls (reduced balance, reduced leg muscle strength and freezing of gait). In addition we will establish the cost effectiveness of the exercise program from the health provider's perspective.

Methods/Design

230 community-dwelling participants with idiopathic Parkinson's disease will be recruited. Eligible participants will also have a history of falls or be identified as being at risk of falls on assessment. Participants will be randomly allocated to a usual-care control group or an intervention group which will undertake weight-bearing balance and strengthening exercises and use cueing strategies to address freezing of gait. The intervention group will choose between the home-based or support group-based mode of the program. Participants in both groups will receive standardized falls prevention advice. The primary outcome measure will be fall rates. Participants will record falls and medical interventions in a diary for the duration of the 6-month intervention period. Secondary measures include the Parkinson's Disease Falls Risk Score, maximal leg muscle strength, standing balance, the Short Physical Performance Battery, freezing of gait, health and well being, habitual physical activity and positive and negative affect schedule.

Discussion

No adequately powered studies have investigated exercise interventions aimed at reducing falls in people with Parkinson's disease. This trial will determine the effectiveness of the exercise intervention in reducing falls and its cost effectiveness. This pragmatic program, if found to be effective, has the potential to be implemented within existing community services.

Trial registration

The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12608000303347).     

Decorticate, decerebrate and opisthotonic posturing and seizures in Kenyan children with cerebral malaria

Background

Intermittent preventive treatment of malaria during pregnancy (IPTp) is a key intervention in the national strategy for malaria control in Tanzania. SP, the current drug of choice, is recommended to be administered in the second and third trimesters of pregnancy during antenatal care (ANC) visits. To allow for a proper design of planned scaling up of IPT services in Tanzania it is useful to understand the IPTp strategy's acceptability to health managers, ANC service providers and pregnant women. This study assesses the knowledge, attitudes and practices of these groups in relation to malaria control with emphasis on IPTp services.

Methods

The study was conducted in February 2004, in Korogwe District, Tanzania. It involved in-depth interviews with the district medical officer (DMO), district hospital medical officer in charge and relevant health service staff at two peripheral dispensaries, and separate focus group discussions (FGDs) with district Council Health Management Team members at district level and pregnant women at dispensary and community levels.

Results

Knowledge of malaria risks during pregnancy was high among pregnant women although some women did not associate coma and convulsions with malaria. Contacting traditional healers and self-medication with local herbs for malaria management was reported to be common. Pregnant women and ANC staff were generally aware of SP as the drug recommended for IPTp, albeit some nurses and the majority of pregnant women expressed concern about the use of SP during pregnancy. Some pregnant women testified that sometimes ANC staff allow the women to swallow SP tablets at home which gives a room for some women to throw away SP tablets after leaving the clinic. The DMO was sceptical about health workers' compliance with the direct observed therapy in administering SP for IPTp due to a shortage of clean water and cups at ANC clinics. Intensified sensitization of pregnant women about the benefits of IPTp was suggested by the study participants as an important approach for improving IPTp compliance.

Conclusion

The successful implementation of the IPTp strategy in Tanzania depends on the proper planning of, and support to, the training of health staff and sustained sensitization of pregnant women at health facility and community levels about the benefits of IPTp for the women and their unborn babies.     

X-Ray Survey Results and Costs—A Health Officer's Viewpoint,A Preliminary Report

The obvious results of a mass chest x-ray survey from a health officer''s viewpoint are:1. The early discovery of unknown cases of pathologic conditions of the chest—tuberculosis, neoplasms, heart abnormalities.2. Increase in the community''s awareness of its tuberculosis problem.3. Opportunity to work closely with the medical society and the individual private physicians.4. Stimulation of all agencies in a community, health and non-health, to work together on a health project for the good of all of the people.5. Increased cooperation between the local department of public health and other health agencies in a community.6. Opportunity to underline to a staff of a local department of public health the importance of thinking in terms of the department as a whole, rather than in terms of respective divisions or bureaus.7. Opportunity to focus the awareness of the community on its public health services.In relation to costs, there are three aspects from a health officer''s viewpoint:1. The planning, together with other agencies, of an adequate budget with full recognition of community resources.2. The planning for estimated expansion of tuberculosis control services both in terms of increased expense for maintenance and operation, and of assignment of personnel to survey staff with resulting curtailment or postponement of other programs.3. The planning for completion of the follow-up program of the x-ray survey and of future continued extension of the total tuberculosis control program as the result of increased community awareness of the tuberculosis problem.     

The use of biomarkers in surveillance, medical screening, and intervention

Building on mechanistic information, much of molecular epidemiologic research has focused on validating biomarkers, that is, assessing their ability to accurately indicate exposure, effect, disease, or susceptibility. To be of use in surveillance, medical screening, or interventions, biomarkers must already be validated so that they can be used as outcomes or indicators that can serve a particular function. In surveillance, biomarkers can be used as indicators of hazard, exposure, disease, and population risk. However, to obtain rates for these measures, the population at risk will need to be assessed. In medical screening, biomarkers can serve as early indicators of disease in asymptomatic people. This allows for the identification of those who should receive diagnostic confirmation and early treatment. In intervention (which includes risk assessment and communication, risk management, and various prevention efforts), biomarkers can be used to assess the effectiveness of a prevention or control strategy as well as help determine whether the appropriate individuals are assigned to the correct intervention category. Biomarkers can be used to provide group and individual risk assessments that can be the basis for marshalling resources. Critical for using biomarkers in surveillance, medical screening, and intervention is the justification that the biomarkers can provide information not otherwise accessible by a less expensive and easier-to-obtain source of information, such as medical records, surveys, or vital statistics. The ability to use validated biomarkers in surveillance, medical screening, and intervention will depend on the extent to which a strategy for evidence-based procedures for biomarker knowledge transfer can be developed and implemented. This will require the interaction of researchers and decision-makers to collaborate on public health and medical issues.     

Benefits of total hip replacement to older patients and the community.

The benefits of total hip replacement in 49 people aged 55-84 with osteoarthrosis of the hip were evaluated. The main benefit was relief of symptoms, 40 patients being pain free after operation. Range of hip movement and mobility improved moderately in most patients. After operation most patients were better able to perform certain activities of daily life, though only six were completely independent, the rest requiring aids or help from others. Nevertheless, 18 of the patients'' main helpers estimated that they had more time free of tasks previously performed for the patient. There was a small reduction in the need for community medical resources such as home visits from general practitioners or district nurses. Thirteen patients were still taking antiarthritic drugs. Older patients needed to spend longer in hospital after operation because of complications. It was concluded that total hip replacement contributed to improving the quality of life of patients and their helpers, while also helping to reduce the demand for community health and welfare services.     

The Role of Gender in Chagas Disease Prevention and Control in Honduras: An Analysis of Communication and Collaboration Networks

In Honduras, where Chagas disease is a serious health and environmental concern, prevention measures face the challenge of achieving widespread and long-term sustainable adoption by communities. The article integrates social network analysis and a gender-sensitive approach to understand the role of men and women in the implementation of a community-level intervention, based on the adoption of housing improvements to reduce the presence of the insect vector. A total of 108 people in the community of El Salitre were interviewed. Data were collected on socio-demographic characteristics, participation in project activities, communication and collaboration networks related to Chagas disease prevention, knowledge of Chagas disease, and adoption of housing improvements techniques. Communication mostly occurred between the same gender individuals and was associated with knowledge of Chagas disease. Socioeconomic status, Chagas disease knowledge, and collaboration with men were associated with women adopting housing improvements. For men, however, participation in project activities, formal education, and collaboration with women were associated with adoption. These findings suggest that men and women were driven by distinct concerns, interests, and motivations when adopting new Chagas disease prevention strategies. Participatory community interventions that seek to generate health knowledge and foster collaborations to reduce health risk should address gender differences.     

Improving communication skill training in patient centered medical practice for enhancing rational use of laboratory tests: The core of bioinformation for leveraging stakeholder engagement in regulatory science

Requests for laboratory tests are among the most relevant additional tools used by physicians as part of patient''s health problemsolving. However, the overestimation of complementary investigation may be linked to less reflective medical practice as a consequence of a poor physician-patient communication, and may impair patient-centered care. This scenario is likely to result from reduced consultation time, and a clinical model focused on the disease. We propose a new medical intervention program that specifically targets improving the patient-centered communication of laboratory tests results, the core of bioinformation in health care. Expectations are that medical students training in communication skills significantly improve physicians-patient relationship, reduce inappropriate use of laboratorial tests, and raise stakeholder engagement.     

Wildland forest fire smoke: health effects and intervention evaluation,Hoopa, California, 1999

Objectives To assess the health effects of exposure to smoke fromthe fifth largest US wildfire of 1999 and to evaluate whether participation ininterventions to reduce smoke exposure prevented adverse lower respiratorytract health effects among residents of the Hoopa Valley National IndianReservation in northwestern California. Design Observational study:epidemiologists from the Centers for Disease Control and Preventionretrospectively reviewed medical records at the local medical center andconducted survey interviews of reservation residents. Setting HumboldtCounty, California. Participants Interviews were completed with 289 of385 residents, representing 26% of the households on the reservation. Of the289 participants, 92 (31.8%) had preexisting cardiopulmonary conditions.Results During the weeks of the forest fire, medical visits forrespiratory illnesses increased by 217 visits (from 417 to 634 visits, or by52%) over the previous year. Survey results indicated that although 181(62.6%) of 289 participants reported worsening lower respiratory tractsymptoms, those with preexisting cardiopulmonary conditions reported moresymptoms before, during, and after the smoke episode. An increased duration ofthe use of high-efficiency particulate air cleaners and the recollection ofpublic service announcements were associated with a reduced odds of reportingadverse health effects of the lower respiratory tract. No protective effectswere observed for duration of mask use or evacuation. ConclusionsTimely actions undertaken by the clinical staff of the local medical centerappeared beneficial to the respiratory health of the community. Futureprograms that reduce economic barriers to evacuation during smoke episodes mayalso improve intervention participation rates and decrease smoke exposures.Although promising, the effectiveness of these and other interventions need tobe confirmed in a prospective community intervention trial.Community smoke exposures resulting from wildland forest fires have beenassociated with increased emergency department and hospital admissions forchronic obstructive pulmonary disease, bronchitis, asthma, and chestpain.^1,2,3Although population expansion into wildland environments continues,interventions to prevent these smoke-related adverse health effects have notbeen validated under conditions of typicaluse.⁴In 1999, the fifth largest wildfire in the United States burned from August23 to November 3 near the Hoopa Valley National Indian Reservation in northernCalifornia. On 15 days, smoke from the fire produced ambient concentrations ofparticulate matter (PM₁₀) on the reservation that exceeded the USEnvironmental Protection Agency''s 24-hour air quality standard of 150μg/m³ of air. On October 21 and 22, particulate concentrationsexceeded the agency''s 24-hour hazardous level of 500 μg/m³.Concern over the health effects of the smoke prompted local officials andmedical officers to implement several interventions to reduce smoke exposurein the community. However, medical personnel were frustrated over the lack ofa scientific basis that could have been used to set public action levels or torecommend appropriate precautionary measures during this emergency. As aresult, on November 5, 1999, the Hoopa Valley Tribal Council requested thatthe Centers for Disease Control and Prevention (CDC) assist them inretrospectively assessing local adverse health effects and evaluating theinterventions that were implemented during the smoke episode.     

Community care for the elderly 1976-84.

The aging of the elderly population is of crucial importance as people who are over 80 make far greater use of health and social services than any other age group. Government guidelines on the provision of services, which are generally related to the whole population aged 65 and over, fail to take account of this change in the age structure of the elderly population and are no longer appropriate. Recent trends in the provision of domiciliary services, day care, specialist housing for the elderly, and residential care have been related to changes in the number of potential consumers. Ironically, despite the government''s stated commitment to "community care," the chief growth area has been private institutional care. The number of day care places and sheltered housing units has also increased in real terms, but the provision of domiciliary services, such as home help and health visitor visits to the elderly, has either fallen behind or barely matched the increase in the number of very old people. If community care is to be made a reality and if the present inadequate levels of service are to be maintained, let alone improved, then additional resources, greater cooperation among agencies, and a more imaginative approach to the development and delivery of services are urgently needed.     

Using Interactive Family Science Shows to Improve Public Knowledge on Antibiotic Resistance: Does It Work?

The public plays an important role in controlling the emergence and spread of antibiotic resistance. A large British survey showed that there is still public misunderstanding about microbes and antibiotics. e-Bug, a European DG Sanco sponsored project, aims to disseminate a school antibiotic and hygiene educational pack and website across Europe. Interactive science shows based on the e-Bug educational packs were developed to take the key health and hygiene messages from the e-Bug school resources to families. The science show was evaluated to assess public knowledge and understanding of antibiotics and antibiotic resistance pre and post intervention. An interactive stall comprised of a 3×2 m backing stand with background information, an interactive activity and discussions with a trained demonstrator was on display at a family holiday resort. Pre-piloted knowledge questionnaires were completed by parents and children pre and post intervention. Adult (≥19 years) baseline knowledge regarding antibiotics and antibiotic resistance was high although significant knowledge improvement was observed where baseline knowledge was low. Children''s (5–11 years) knowledge around antibiotics and antibiotic resistance was significantly improved for all questions. The science show can be viewed as a success in improving parents'' and children''s knowledge of antibiotic use thereby highlighting the importance of educating the public through interaction.     

Women in medicine: practice patterns and attitudes.

Increasing numbers of women are entering medicine in Canada. In 1959 women accounted for 6% of the medical school graduates, but by 1989 they accounted for 44%. Although there has been little systematic investigation of the impact of this increase on Canada''s health care system, there are grounds for believing that female physicians bring with them distinctive values and interests, which may be reflected in the way they conduct their professional practices. We used data from a recent national survey of 2398 Canadian physicians to examine differences between women and men in their practices and their attitudes toward health care issues. Significant differences were found in the organization and management of the practices. Women preferred group over solo practice and were overrepresented in community health centres, health service organizations and centres locaux de services communautaires in Quebec. One-third of the women, as compared with half of the men, were in specialties. Even after adjusting for differences in workloads the incomes of the women were significantly lower than those of the men. Only minor differences were observed in the assessment of the health care system and alternative modes of organizing health care services. We believe that the differences were due to the double workload of women as professionals and family caregivers and the powerful socialization effects of medical education. As women overcome their minority status in the medical profession, differences between the sexes may become more apparent. Thus, the extent and effects of the progressive increase in the number of women in Canadian medicine should be assessed on an ongoing basis.     

Allocating resources to health authorities: development of method for small area analysis of use of inpatient services.

Every year about 22 billion pounds is allocated to health authorities for hospital and community services in England. The distribution of most of these funds is based on a formula developed to reflect the population''s needs, but the existing formula has been criticised on several grounds. This paper describes the development of a method to determine the health needs for small geographical areas. Data from the hospital episodes statistics and 1991 census together with information on vital statistics and supply of health care facilities were used in the model. Two stage least squares regression was used to identify true indicators of need, and these were entered into a multilevel model to take account of variations in practice in different health authorities. The resulting formula should be more statistically robust and more sensitive to needs than previous approaches.