Search PubMed⌕ Search

Biomedical subjects

V Diwan

Publications and source records attributed to V Diwan.

At least 19 recordsLinked to original sources
PubMed2006

Health care seeking among individuals with cough and tuberculosis: a population-based study from rural India.

SETTING: Ujjain district, Madhya Pradesh, India. OBJECTIVE: To describe and compare health care seeking among men and women with cough of >3 weeks, with special focus on the utilisation of private and public health care. DESIGN: A population-based cross-sectional survey including 45 719 individuals aged > or = 15 years. RESULTS: The prevalence of cough was respectively 2.8% and 1.2% among men and women. The majority of men and women reported seeking health care for their symptoms (69% vs. 71%), but only 23% visited a public provider at some point during their illness. A similar health care seeking pattern was found for patients diagnosed with tuberculosis (TB) in our survey. No significant differences in health care seeking were found between men and women. Only 13% of those seeking care reported having had a sputum smear examination since the onset of cough. Factors associated with sputum examination were history of TB, haemoptysis and visiting a public provider. CONCLUSION: The low utilisation of public health care services and the few sputum examinations reported in this rural Indian setting illustrate the need for improved diagnostic practices as well as involvement of private providers in TB control activities.

Adolescent↗
PubMed2003

DOTS for temporary workers in the agricultural sector. An exploratory study in tuberculosis case detection.

INTRODUCTION: This study was conducted in the Boland health district of the Cape Winelands of South Africa where there is a high tuberculosis incidence and prevalence. A survey conducted on 211 farms in the study district during 1998, reported that 65% (n = 9042) of all workers on these farms, were temporarily employed. Temporary farm workers live in communities either within or the outskirts of the boundaries of the Boland health district, from where they are transported to work daily. RESEARCH OBJECTIVE: To estimate the point prevalence of sputum smear-positive tuberculosis among temporary farm workers in the Boland health district, and to determine whether temporary farm workers diagnosed with tuberculosis, have access to anti-tuberculosis treatment. STUDY DESIGN: The study took the form of a cross-sectional active case finding survey amongst adult temporary farm workers (not living on farms) on the four study farms in the Boland health district. RESULTS: Data was analysed using the Epi Info Version 6 computer programme. Four (4) existing (self-reported) tuberculosis cases were identified and six (6) previously undiagnosed new sputum smear-positive cases of tuberculosis were detected. The total point prevalence was 10 cases of tuberculosis in the cohort of temporary farm workers, resulting in a point prevalence rate of 2,809 cases per 100,000 temporary farm workers (95% CI 1,090-4,527). If the four (4) self-reported cases of tuberculosis are excluded in the calculation, the point prevalence of new sputum smear-positive tuberculosis cases is six (6) and the prevalence rate 1,685 cases per (95% CI 468-2909). Of the four self-reported tuberculosis cases, one indicated that their supply of medication was depleted, whereas the other three indicated that they had the required treatment at home. DISCUSSION: Tuberculosis is a major health problem in this region of South Africa and the incidence is projected to increase in correlation with the increasing prevalence of HIV/AIDS. Recent legislative changes in South Africa have resulted in a trend where farmers decrease their permanent work force and increase their use of a temporary work force. The nature of temporary employment in the agricultural industry creates potential difficulties for farm workers to access tuberculosis health care. The early detection and effective case management of this high-risk group presents a special challenge to the South African health community.

Agricultural Workers' Diseases↗
PubMed2001

Can I afford free treatment?: Perceived consequences of health care provider choices among people with tuberculosis in Ho Chi Minh City, Vietnam.

Vietnam has a well-organised National TB Control Programme (NTP) with outstanding treatment results. Excellent prospect of cure is provided free of charge. Still, some people prefer to pay for their TB treatment themselves in private clinics. This is a potential threat to TB control since no notification of cases treated in the private sector occurs, and there is no control of the effectiveness of treatment provided in private clinics. Using a qualitative approach within a grounded theory framework, this study explores health-seeking behaviour among people with TB, applying a specific focus on reasons for choices of private versus pubic health care providers. The study identifies a number of characteristics of private TB care, which both seem attractive to patients and at the same time contrast sharply with the structure of the NTP strategy. These include flexible diagnostic procedures, no administrative procedures to establish eligibility for treatment, flexible choices of drug regimens, non-supervised treatment (no DOT), no tracing of defaulters in the household, no official registration of TB cases and thus less threat to personal integrity. A possibility to demand individualised service through the use of fee-for-service payments directly to physicians also seems attractive to many patients. A number of the components of the NTP strategy that have been put in place in order to secure optimal public health outcomes are lacking in the private sector. A dilemma for TB control is that this seems to be an important reason for why many people with TB opt for private providers where quality of care is virtually uncontrolled. The global threat of TB has led to calls for forceful measures to control TB. However, based on the findings in this study it is argued that the use of rigid approaches to TB control that do not encompass a strong component of responsiveness towards the needs of individuals may be counterproductive for public health.

Anecdotes as Topic↗
PubMed2001

Antiepileptic drug therapy and its management in sudden unexpected death in epilepsy: a case-control study.

PURPOSE: Because frequent seizures constitute a major risk factor for sudden unexpected death in epilepsy (SUDEP), the treatment with antiepileptic drugs (AEDs) may play a role for the occurrence of SUDEP. We used data from routine therapeutic drug monitoring (TDM) to study the association between various aspects of AED treatment and the risk of SUDEP. METHODS: A nested case-control study was based on a cohort consisting of 6,880 patients registered in the Stockholm County In Ward Care Register with a diagnosis of epilepsy. Fifty-seven SUDEP cases, and 171 controls, living epilepsy patients, were selected from the cohort. Clinical data including data on TDM were collected through medical record review. RESULTS: The relative risk (RR) of SUDEP was 3.7 (95% CI, 1.0-13.1) for outpatients who had no TDM compared with those who had one to three TDMs during the 2 years of observation. RR was 9.5 (1.4-66.0) if carbamazepine (CBZ) plasma levels at the last TDM were above and not within the common target range (20-40 microM). High CBZ levels were associated with a higher risk in patients receiving polytherapy and in those with frequent dose changes. Although the subgroup of patients with high CBZ levels was small (six cases of 33 with CBZ therapy), and the result should be interpreted with caution, no similar associations were demonstrated for phenytoin plasma levels and risk of SUDEP. No association was found between SUDEP risk and within-patient variation in AED levels over time. CONCLUSIONS: Polytherapy, frequent dose changes, and high CBZ levels as identified risk factors for SUDEP all point to the risks associated with an unstable severe epilepsy. It is unclear whether high CBZ levels per se represent a risk factor or just reflect other unidentified aspects of a severe epilepsy. Our results, however, prompt further detailed analyses of the possible role of AEDs in SUDEP in larger cohorts and suggest that reasonable monitoring of the drug therapy may be useful to reduce risks.

Adolescent↗
PubMed2001

Feasibility of home-based and health centre-based DOT: perspectives of TB care providers and clients in an HIV-endemic area of Thailand.

Focus groups were conducted in a high human immunodeficiency virus (HIV) prevalence area of Thailand to elicit perspectives of health staff and clients regarding the feasibility of directly observed therapy (DOT) for tuberculosis. Most participants perceived health centre-based DOT to be impractical for clients due to severe illness, travel inconvenience, and interference with employment. Most providers perceived home-based DOT to be difficult because of the inconvenience of travel, staff shortages and the high tuberculosis caseload. Most clients except HIV-negative tuberculous females considered home visits to be undesirable due to stigma. The preparedness of providers for home-based DOT might be improved through awareness building among staff about multidrug-resistant tuberculosis.

Adult↗
PubMed2001

Health seeking behaviour and diagnosis for pulmonary tuberculosis in an HIV-epidemic mountainous area of Thailand.

SETTING: Chiang Rai Hospital, Chiang Rai Province, the epicentre of the human immunodeficiency virus (HIV) in Thailand. OBJECTIVE: To describe the health seeking behaviour among tuberculosis (TB) patients, to measure patient and provider delays and to analyse factors determining these delays. DESIGN: All patients aged over 15 years with new smear-positive pulmonary TB detected in Chiang Rai Hospital (n = 557) were interviewed using a structured questionnaire. RESULTS: The median patient delays for HlV-positive and HIV-negative patients and those whose HIV status was unknown were 10, 15 and 15 days respectively, while provider delays were respectively 7, 7.5 and 10 days. HIV-positive patients suffered more symptoms and had a shorter patient's delay. Risk factors of long patient delay (>21 days) included being HIV-negative, having no health insurance, hill tribe ethnicity, no previous visits to the hospital, and borrowing money for hospital visits. Multivariate logistic analysis suggested that being married or widowed and being HIV-positive led to the shortest patient delay. Provider delay was significantly longer in female patients than male patients. CONCLUSION: Although patient and provider delays were favourably short, certain specific groups require further attention. Hill tribe people should be targeted to improve accessibility to TB treatment. Active case-finding services for people known to be HIV-positive should be encouraged. The reasons for the longer provider delay in female patients require further investigation.

AIDS-Related Opportunistic Infections↗
PubMed2000

High AIDS awareness may cause tuberculosis patient delay: results from an HIV epidemic area, Thailand.

OBJECTIVE: To elicit community perceptions about tuberculosis (TB) and the behaviour of TB patients in an area where significant public health attention has been focused on AIDS. SETTING: Chiang Rai, Thailand, the epicentre of HIV/AIDS in this country. DESIGN: Eleven focus group sessions with a cross-section of the population. PARTICIPANTS: Health centre staff, community members, persons having HIV, TB patients (with and without HIV infection), and male injecting drug users; five female groups and six male groups. RESULT: People had good knowledge of AIDS but they knew little about TB. Only a few female patients, whose husbands had died of TB and AIDS, recognized their symptoms as TB and immediately sought care. People defined persons losing weight, having fever and cough as AIDS rather than TB. This resulted in delay in seeking care and non-adherence to TB treatment in some patients who suspected they had AIDS, and feared AIDS detection. Most HIV-negative TB patients were also suspected by their relatives and neighbours of having AIDS. Most participants, except HIV-positive females, believed TB to be curable. Although less than AIDS, the community stigmatized TB patients because of it being contagious and easily transmitted through exhalations, foods and drinks and closeness to TB patients. CONCLUSION: In HIV/AIDS high endemic situation, increased awareness and stigmatization of AIDS and inadequate knowledge of TB can result in delay in seeking TB care and in treatment non-adherence.

AIDS-Related Opportunistic Infections↗
PubMed2000

Household survey of injuries in a Kenyan district.

OBJECTIVE: To determine the pattern and burden of injuries, their causes and action taken in a rural and urban community in Kenya. DESIGN: Household interview survey and focus group discussions. SETTING: Four rural villages and five urban clusters in Kiambu District, Kenya. SUBJECTS: A total of 1,980 members of 200 rural and 230 urban households. RESULTS: The number of reported injuries was 495, corresponding to 300,000 injuries per 100,000 people per year. Most common were cut or piercing (38.4%), followed by fall (16.2%), burn or scald (14.3%), animal bite or kick (10.1%), hit by moving object (5.9%) and road traffic accident (3.6%). Poisoning, sub-mersion/drowning and explosion were uncommon, each below three per cent. Of all reported injuries, 149 (30.1%) sought care from traditional healers, 91 (18.4%) were subject to self-care, 76 (15.4%) obtained service from drug shops, 22 (4.4%) were brought to a health facility for attention and 17 (3.4%) took no action at all. Additional information was obtained through focus group discussions with students, teachers and members of women groups. These generated detailed information about cases of sexual assault within and outside households which had not been captured during the previous household interviews. CONCLUSION: Injuries are very common but most of them are mild, prompting only home care or no action at all. Only one out of 25 injuries were brought to a health facility for attention. Some types of injury, such as domestic violence and sexual assault, are more likely to be captured through focus group discussions than during household interviews. A combination of methods is likely to best reflect the pattern of injury at community level.

Adolescent↗
PubMed1999

Association between health insurance and antibiotics prescribing in four counties in rural China.

A cross-sectional study was carried out at county, township and village health care facilities in four counties in rural China in order to describe and compare the effects of health financing systems on antibiotic prescribing in outpatient care. A total of 1232 outpatients at the health care facilities was selected by multi-stage random sampling and were interviewed over 2 weeks. The results showed that health financing systems appeared to influence antibiotic prescribing in outpatient care, both in terms of frequency and of the types prescribed. The insured group had lower prescribing of antibiotics at township and village health care facilities, and for respiratory tract infections, but had higher prescribing of newer antibiotics at county and village health care facilities, for respiratory tract and g-i infections. Because there was a high patient compliance rate (94.3%) in this study the prescribing of antibiotics (supply side behavior) reflected the use of antibiotics (demand side behavior) to a great extent. Thus the results imply that antibiotics prescribing and using might be biased by the patient's health financing systems and antibiotic prescribing was the result of the interaction between physicians and patients.

Anti-Bacterial Agents↗
PubMed1999

Drug policy in China: pharmaceutical distribution in rural areas.

In 1978, China decided to reform its economy and since then has gradually opened up to the world. The economy has grown rapidly at an average of 9.8% per year from 1978 to 1994. Medical expenditure, especially for drugs, has grown even more rapidly. The increase in medical expenditure can be attributed to changing disease patterns, a higher proportion of older people in the population and fee-for-service incentives for hospitals. Due to the changing economic system and higher cost of health care, the Chinese government has reformed its health care system, including its health and drug policy. The drug policy reform has led to more comprehensive policy elements, including registration, production, distribution, utilization and administration. As a part of drug policy reform, the drug distribution network has also been changed, from a centrally controlled supply system (push system) to a market-oriented demand system (pull system). Hospitals can now purchase drugs directly from drug companies, factories and retailers, leading to increased price competition. Patients have easier access to drugs as more drugs are available on the market. At the same time, this has also entailed negative effects. The old drug administrative system is not suitable for the new drug distribution network. It is easy for people to get drugs on the market and this can lead to overuse and misuse. Marketing factors have influenced drug distribution so strongly that there is a risk of fake or low quality drugs being distributed. The government has taken some measures to fight these negative effects. This paper describes the drug policy reform in China, particularly the distribution of drugs to health care facilities.

China↗
PubMed1999

Health financing policies. Providers' opinions and prescribing behavior in rural China.

OBJECTIVES: To describe effects of health financing on providers' opinions and prescribing behavior in rural China. METHODS: A multi-stage sampling procedure was used to select county, township, and village health care facilities. A total of 1,064 health care providers in county, township, and village health care facilities in six counties in central China were randomly selected and surveyed during one week by written questionnaire. RESULTS: Patient's health financing systems (insurance or out-of-pocket payment), financing methods for health facilities (general budget or fee for service), and payment methods for providers (salary or bonus) influenced provider prescribing. Bonuses could improve the quality of health care, but could also be an incentive to prescribe more drugs or more expensive drugs and other services. The providers were of the view that patients' health financing and ability to pay were the main determinants of the type of treatment. Insured patients could have more access to expensive drugs, referred to specialized health care facilities, and have a higher cure rate (according to the doctor's opinion) for tuberculosis. Most of the clinical doctors said that they prescribed more expensive antibiotics for insured patients and changed prescriptions according to patients' demands, financial ability, and health financing systems in the treatment of some diseases, such as chronic bronchitis, tuberculosis, and hypertension. CONCLUSION: The empirical data suggest that the main factor influencing provider prescribing behavior is the economic incentives in relation to health care financing for both health care providers and consumers.

Adult↗
PubMed1998

Risks and benefits of private health care: exploring physicians' views on private health care in Ho Chi Minh City, Vietnam.

As in a number of other low- and middle-income countries, the health sector in Vietnam is transforming with a rapid shift from fully state run and financed health care towards more private financing and delivery of health care. This development has been particularly noticeable in the largest city in the country, Ho Chi Minh City, where a majority of physicians now are practising in private clinics and where the private health care sector is an increasingly popular option for people. While the private sector is an important part of the health care system in Vietnam, few data are available on the characteristics and quality of private health care services. This case study describes some aspects of the re-emerging private health care sector in Ho Chi Minh City, Vietnam, from the view of 27 private and non-private physicians. The paper explores physicians' reasons for going private, physicians' notions of patients' health care preferences, and physicians' views on potential influence of financial incentives on characteristics of private health care. The characteristics of private health care are discussed in relation to a context of private health care characterised by a fully patient-financed fee-for-service payment system, weak regulatory mechanisms, and a public health care system (government-run and-financed health care) that operates under resource constraints. Issues to consider when attempting to steer private health care in Vietnam in a direction where it can optimally contribute to public health, are discussed while considering the interplay between authorised private practitioners, private pharmacies, the informal private sector, and the public health care sector.

Adult↗
PubMed1997

Cause-specific mortality in epilepsy: a cohort study of more than 9,000 patients once hospitalized for epilepsy.

PURPOSE: We studied overall and cause-specific mortality rates in a large cohort of patients with epilepsy compared with mortality rates of the general population in the same geographic area. METHODS: The cohort consisted of all patients (N = 9,061) aged > 15 years admitted with a diagnosis of epilepsy for inpatient care in Stockholm during the years 1980-1989. All patients were followed in the National Cause-of-Death Register, from which the causes of death were obtained, until December 31, 1992. Thus, 53,520 person-years were observed. Mortality rates were compared with those of the general population of Stockholm. RESULTS: We observed 4,001 deaths in the cohort, compared with an expected number of 1,109 deaths in the general population. This yielded a standardized mortality ratio (SMR) of 3.6 [95% confidence interval (CI) 3.5-3.7]. Although highest in the younger patients, the SMR was significantly increased in all age groups. The excess mortality rate in the cohort was due to a wide range of causes of death, including malignant neoplasms [SMR 2.6 (2.4-2.8)], diseases of the circulatory system, [SMR 3.1 (3.0-3.3)], diseases of the respiratory system [SMR 4.0 (3.6-4.5)], diseases of the digestive system [SMR 5.1 (4.4-5.8)], and injuries and poisoning [SMR 5.6 (5.0-6.3)]. CONCLUSIONS: Our results demonstrate that this large subgroup of patients with a diagnosis of epilepsy, once hospitalized and discharged, is a population at risk, with an excess mortality rate due to several different causes.

Accidents↗
PubMed1996

Population policies and reproductive patterns in Vietnam.

BACKGROUND: Vietnam's population policy since the 1980s had stipulated a limit on family size to two children, born 3-5 years apart, and recommends a minimum age of 19 for the mother of a first child. We analysed trends in the timing of marriages and births, and in fertility and abortion rates, among women born between 1945 and 1970, to assess the impact of these policies on reproductive patterns. METHODS: Reproductive histories were recorded in a random sample of 1432 married women aged 15-49 in a rural province in northern Vietnam. Mean age at marriage and at birth of the first child, birth intervals, fertility, and abortion rates were examined in relation to the woman's year of birth. FINDINGS: Later-born women married and had their first child at a younger age than women born earlier. Birth intervals had increased among later-born women but 25% still had only a 1-year interval between first and second child. Fertility had gradually decreased while abortion ratios had increased rapidly. Childbearing patterns had become "earlier, longer, and fewer" rather than "later, longer, and fewer" as stipulated by the policies. The results also show that women with more schooling married and had their first child later. Women involved in farming had shorter spacing between children. INTERPRETATION: There are signs that Vietnam's population policy has focused too strongly on contraception and abortion while ignoring the connection between fertility and women's opportunities for education and employment. In these respects, rural women are at particular risk.

Abortion, Induced↗
PubMed1994

Human immunodeficiency virus type-1 infection in Zambian children with tuberculosis: changing seroprevalence and evaluation of a thioacetazone-free regimen.

SETTING: This study was conducted at the Department of Paediatrics and Child Health, University Teaching Hospital (UTH), in Lusaka, Zambia. OBJECTIVES: To monitor the seroprevalence of HIV type-1 in children with tuberculosis and to evaluate the response to anti-tuberculosis therapy using a thioacetazone-free treatment regimen. DESIGN: A prospective cross-sectional study of all consecutive newly diagnosed cases of TB in children from 1 month-15 years of age seen at the University Teaching Hospital (UTH) in Lusaka, Zambia between 1 October 1991 and 31 May 1992. RESULTS: 120 children with a clinical diagnosis of tuberculosis and 167 controls were enrolled in the study. The overall HIV type-1 seroprevalence rate in children with tuberculosis was 55.8% (67/120) compared to 9.6% (16/167) amongst the control group (P < 0.0001: odds ratio = 11.50; 95% CI = 5.99-22.7). Common clinical presentations among children with TB were bronchopneumonia (45/162), miliary TB (30/162) and tuberculous lymphadenopathy (21/33). There were no significant differences in clinical presentation of TB between the HIV-negative and HIV-positive groups. The follow-up of those patients with tuberculosis was poor, with only 65 patients (55%) returning to the clinic for scheduled appointments after discharge. All the 16 patients who died did so within 60 days of discharge from hospital; all of them were seropositive for HIV. There were no deaths among the HIV-negative group. Despite the exclusion of thioacetazone from the treatment regimen, cutaneous reactions occurring within 8 weeks of commencing treatment were observed in 7 of the 65 (11%) patients, 2 of whom developed fatal Stevens-Johnson syndrome. All 7 patients were seropositive for HIV-1. CONCLUSIONS: The seroprevalence rate of HIV type-1 among children with tuberculosis in Lusaka continues to rise; careful monitoring of anti-TB therapy (even in regimens excluding thioacetazone) for potentially lethal side effects should be carried out.

Adolescent↗
PubMed1993

Seroprevalence of human immunodeficiency virus type 1 infection in Zambian children with tuberculosis.

Descriptions in the medical literature of human immunodeficiency virus type 1 (HIV-1) in children with tuberculosis (TB) are scanty. This study determined the seroprevalence of HIV-1 in 237 hospitalized children between the ages of 1 month and 14 years with a clinical diagnosis of TB (125 males and 112 females) and in 242 control children (149 males and 93 females). The overall HIV-1 seroprevalence rate in patients with TB was 37% (88 of 237) compared with 10.7% (26 of 242) among the control group (P < 0.00001: odds ratio 5.37, 95% confidence interval = 3.21 < 5.37 < 9.47). HIV-1 seropositivity in children with TB ranged from 53% (31 of 58) in the 12- to 18-month age group to 14% (9 of 61) in the 10- to 14-year-olds. The risk of TB attributable to HIV infection was 29%. The predominant clinical presentation in both seronegative (84.6%) and seropositive (89.7%) groups was that of pulmonary TB and there were no significant differences in clinical presentation between the two groups of patients. Only 54.8% of the patients attended follow-up clinics regularly whereas 32% were lost to follow-up within 3 months. Bacillus Calmette-Guérin vaccination coverage was 87.3% among TB patients and 90.5% in the controls. No significant differences in B. Calmette-Guérin vaccination rates between the seronegative and seropositive children were seen. Coinfection with HIV and TB in children is now one of the major public health problems in Zambian children.

AIDS-Related Opportunistic Infections↗