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Biomedical subjects

A Zwi

Publications and source records attributed to A Zwi.

At least 19 recordsLinked to original sources
PubMed2004

Experience of domestic violence by women attending an inner city accident and emergency department.

OBJECTIVES: To identify the prevalence of domestic violence (DV) (defined as physical abuse perpetrated by intimate partners) in women attending an inner city accident and emergency department and to elicit women's response about being asked routinely about domestic violence in this setting. METHODS: 22 nursing shifts were purposefully sampled to be representative of day, night, and weekends. A questionnaire was administered to 198 consenting women who were not intoxicated, confused, or critically ill. RESULTS: The prevalence of acute trauma in women attributable to DV was 1% (95%CI 0.14 to 3.6), the prevalence of lifetime physical abuse was 34.8% (95%CI 28.2 to 41.5), of past year physical abuse was 6.1% (95%CI 3.2 to 10.3), and of lifetime life threatening physical abuse was 10.6% (95%CI 6.3 to 14.9). Seventy six per cent of women felt comfortable about being asked about DV and 60.5% of women felt that they should always or usually be asked about DV in this setting. CONCLUSION: This cross sectional survey adds to the body of knowledge showing that the prevalence of DV in women attending an accident and emergency department is high. Most women were in favour of being asked, and disclosure was associated with discomfort in few women. This sensitive area of history taking and referral could be undertaken by health professionals using a supportive approach.

Adolescent↗
PubMed2000

Health policy-making in central and eastern Europe: lessons from the inaction on injuries?

The burden of disease due to injuries has elicited virtually no public health response in the countries of central and eastern Europe, even though injuries have long been a much greater problem in the east of Europe than in the west, with children especially affected. This paper seeks to identify factors that have inhibited policy development on this topic and to draw lessons for health policy development in this region more generally. Several factors emerge. Deaths from injuries have had low visibility. Data have not been assembled in a way that would facilitate identification of the burden of disease that they constitute. Those organizations responsible for public health, whether within government or at local level, were typically very weak with little capacity either to identify the nature and scale of threats to the health of their populations or to develop strategies to address them. There was uncertainty about ownership, with fragmentation of responsibility but no tradition of intersectoral working. Non-governmental organizations, which have placed injuries on the health policy agenda in the west, are weak or non-existent. International donors, who could have had a role, have focused on issues such as health care reform. This analysis provides a potential framework for examining policy responses, or lack thereof, to other health challenges in this region. It highlights the need for a better understanding of the potential for using available data, which, in turn, requires a major strengthening of capacity. However, in many countries, there is a need for new ways of working, involving a broadening of the sense of ownership, with clearly designated responsibilities but designed in ways that encourage rather than inhibit intersectoral action. There is also a need to develop non-governmental organizations that have sufficient capacity to undertake their own analyses and to place issues on the agenda.

Child↗
PubMed1999

Viewpoint: management of malaria--working with the private sector.

Recent reviews have demonstrated that a substantial proportion of cases of malaria are managed in the private sector, and international policy initiatives routinely emphasize the need for malaria control programmes to collaborate with the private sector. However, information on how to develop successful partnerships between the public and private sectors remains limited. This paper reviews the current knowledge about the management of malaria by private providers, considers the potential of different strategies for influencing the quality of care provided, and identifies processes for facilitating public-private sector collaborations. We contend that public sector-led interventions, such as training of private providers or the distribution of prepackaged antimalarials through the private sector, are unlikely to scale up to sustainable national level programmes if they do not take into account a wide range of needs and concerns, represented by private provider organizations and other interest groups, including service users. These groups should be involved at key stages including the design and piloting of interventions, through to the dissemination and implementation of findings. Research priorities are outlined for the development of tools to facilitate public-private partnerships for improving the management of malaria.

Antimalarials↗
PubMed1999

Shifting the paradigm in tuberculosis control: illustrations from India.

Drawing on literature from India and key contributions from social science, this paper asks and attempts to answer the question 'who is to blame for treatment failures in TB'? Some key lessons emerge: effective tuberculosis control cannot be achieved so long as the disease is considered in isolation from the social processes that maintain it, create the conditions facilitating its spread and act as barriers to care. Insights into the economic and social burdens incurred with a diagnosis of TB are essential to understand why many patients, especially the most disadvantaged, are unable to comply with treatment regimens. TB and health care interventions need to be appropriate to the health service contexts in which they are applied, and sensitive to the competing demands, needs and priorities of people's lives. The paper argues for the need to reorient TB control programmes towards enabling patients to obtain care. The problem of access emerges as central to people's ability to obtain and maintain appropriate therapy. Examples and characteristics of successful non-governmental projects, from which policy makers, programmers and practitioners could learn, are outlined and contrasted with more rigid directly observed treatment approaches. We conclude that treatment failures are not patient failures, and that TB control programmes need to address the social dimensions of TB, and adhere to the principles of good TB care, with the same commitment that is devoted to ensuring patients follow treatment guidelines. We suggest a paradigm shift away from a focus on diseased patients towards enabling health in the community.

Antitubercular Agents↗
PubMed1998

Improving the quality of private sector delivery of public health services: challenges and strategies.

Despite significant successes in controlling a number of communicable diseases in low and middle income countries, important challenges remain, one being that a large proportion of patients with conditions of public health significance, such as tuberculosis, malaria, or sexually transmitted diseases, seek care in the largely unregulated 'for profit' private sector. Private providers (PPs) often offer services which are perceived by users to be more attractive. However, the available evidence suggests that serious deficiencies in technical quality are often present. Evaluations of interventions to promote evidence-based care in high income countries have shown that multi-faceted strategies which increase provider knowledge have had some success in improving service quality. A wider range of factors needs to be considered in low and middle income countries (LMICs), especially factors which contribute to discrepancies between provider knowledge and practice. Studies have shown that PPs, especially, perceive or experience patient and community pressures to provide inappropriate treatments. LMIC governments also lack the capacity to enforce regulatory controls. Context-specific multi-faceted strategies are needed, including the local adaptation and dissemination to providers of relevant evidence, the education of patients and communities to adopt effective treatment-seeking and treatment-taking behaviour, and feasible mechanisms for ensuring and monitoring service quality, which may include a role for self-regulation by provider organizations or provider accreditation. Developing, implementing and evaluating strategies to improve the quality of service provision will depend on the involvement of the key stakeholders, including policy makers and PPs. Focusing on studies from Asia, Africa and Latin America, this paper develops a model for identifying the influences on PPs, mainly private medical practitioners, in their management of conditions of public health significance. Based on this, multi-faceted strategies for improving the quality of treatment provision are suggested. Interventions need to be inexpensive, practical, efficient, effective and sustainable over the medium to long term. Achieving this is a significant challenge.

Developing Countries↗
PubMed1998

A flow diagram to facilitate selection of interventions and research for health care.

Decisions about health care should be informed by systematic review of valid research evidence on the effects of interventions on health outcomes that matter. If systematic review suggests it is likely that a health care intervention does more good than harm in some settings, questions must be addressed about the local applicability of the intervention, its cost-effectiveness, and feasibility of implementation. If systematic review suggests that it is unlikely that an intervention does more good than harm in any setting, its use should be discouraged, while existing interventions are improved or alternative interventions developed. If it is uncertain whether an intervention does more good than harm, further analysis of existing data or new controlled trials are required. The article contains a flow diagram, which provides a structure for making such decisions.

Cost-Benefit Analysis↗
PubMed1997

Health policy development in wartime: establishing the Baito health system in Tigray, Ethiopia.

This paper documents health experiences and the public health activities of the Tigray People's Liberation Front (TPLF). The paper provides background data about Tigray and the emergence of its struggle for a democratic Ethiopia. The origins of the armed struggle are described, as well as the impact of the conflict on local health systems and health status. The health-related activities and public health strategies of the TPLF are described and critiqued in some detail, particular attention is focused on the development of the baito system, the emergent local government structures kindled by the TPLF as a means of promoting local democracy, accountability, and social and economic development. Important issues arise from this brief case-study, such as how emerging health systems operating in wartime can ensure that not only are basic curative services maintained, but preventive and public health services are developed. Documenting the experiences of Tigray helps identify constraints and possibilities for assisting health systems to adapt and cope with ongoing conflict, and raises possibilities that in their aftermath they leave something which can be built upon and further developed. It appears that promoting effective local government may be an important means of promoting primary health care.

Communicable Disease Control↗
PubMed1994

Beyond 'clinical'?: four-dimensional medical education.

Medical education is in crisis. Undergraduates experience an excessive burden of information, develop attitudes to learning that are based on passive acquisition of knowledge than on curiosity and exploration, and suffer from progressive disenchantment with medicine. There is also a serious problem of providing adequate clinical experience for medical students at existing teaching sites, largely because of reduction in bed numbers, increased patient throughput and clinical specialization. This problem was identified over a decade ago in London but has not been solved by the merger of medical schools. A recent survey in one London teaching hospital showed underemployment of students and limited patient contact. A review of clinical clerkships in an Australian medical school revealed that one-third of teachers were perceived as unconcerned, discouraging, derogatory or hostile, and only one-half were rated as effective educators. One consequence has been the development of a wide-ranging debate on changing medical education. Traditionalists have diminishing room for manoeuvre in defence of existing educational practices, as cautious bodies like the General Medical Council (GMC) opt for fundamental reform.

Community Medicine↗
PubMed1994

Carrot and stick: state mechanisms to influence private provider behavior.

The behavior of private sector health care providers will depend critically on the environment within which they operate. A bewildering array of possible regulatory and incentive setting structures exist. Most developing countries have the basic legislation for regulation, but there are frequently difficulties in enforcing such controls. While process aspects of quality of care regulation are often the responsibility of professional organizations, these organizations may have limited incentives to be active in ensuring high quality medical car.e There has been less experience with the use of incentives to encourage appropriate behavior amongst private providers: this appears a promising area for further work. Above all, adequate information is essential both for the enforcement of regulations and the application of incentive mechanisms.

Consumer Organizations↗
PubMed1993

Health professionals and South Africa: supporting change in the health sector.

Now that political change is on the way in South Africa, what should be the position of doctors who are invited to visit the country? Does the "academic boycott" still have relevance? Waterston and Zwi review the case for and against an academic boycott policy, using evidence collected during the recent visit by Physicians for Human Rights (UK) and the Johannes Wier Foundation. The health system in South Africa is still inequitable, and despite progress towards desegregation in hospitals there is little momentum towards universal provision of primary health care, especially in the rapidly growing townships around big cities. The authors consider that pressure on the government should be maintained by outside organisations but that support directed towards appropriate health care should be encouraged, particularly in public health and primary health care.

Attitude↗