Patient navigation: a community based strategy to reduce cancer disparities.
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Community Health Services↗
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Measles immunization with further attenuated heat-stable measles vaccine using five different methods of administration.
Further attenuated heat-stable measles vaccine Attenuvax was administered randomly to 109 children using five different methods and a control group (24). Vaccine administration by syringe and needle (0.5 ml) and by jet-injector (0.1 ml) resulted in a high percentage of significant HAI measles antibody titres (greater than or equal to 1:24). Vaccine administration by nose drops (0.5 ml), bifurcated needle or needle planted cylinder did not yield satisfactory levels of serum antibody. Morbidity measured over a period of four weeks after administration showed a moderate increase of respiratory symptoms over the controls. Children who showed a positive tuberculin PPD reaction after BCG immunization did not differ from children with a negative tuberculin reaction in regard to their ability to produce a Kenya. The aim was to find a simpler method of administration of this improved vaccine, suitable for community health workers. The vaccine was shown to be less stable under field conditions than suggested by previous reports.
Antibodies, Viral↗
Risk indicators of childhood undernutrition in Kingston, Jamaica.
In Jamaica, early childhood undernutrition remains a problem; however, the health of all children cannot be monitored due to limited resources. Therefore, there is a need for the early identification of children at risk of undernutrition. A simple screening instrument for use by paraprofessionals in the primary health care system was developed. We conducted a case-control study using 649 children, aged 6 to 48 months. The cases were undernourished (weight-for-age less than 80% of the reference) and identified from a survey. The children's guardians were given a questionnaire comprising 31 variables thought to be associated with undernutrition and which were present from 6 weeks of age. Nine variables were significantly associated with undernutrition. Multiple logistic regression analysis indicated that low birth weight, short birth spacing, being born at home, poor ante-natal and post-natal clinic attendance, overcrowding and a lack of house-hold possessions were independent predictors of undernutrition. Using these variables, a simple scoring system was developed to identify high risk children. It had a sensitivity and specificity of 56% and 76% respectively and a positive predictive values of 31%. This simple screening instrument should be easy to use in the primary health care system. However, its low sensitivity indicates that it is difficult to identify children who are at risk of undernutrition from 6 weeks of age. Subsequent high morbidity and poor child care which were not measured may account for some of the missed cases.
Birth Intervals↗
Nutritional supplementation, psychosocial stimulation, and mental development of stunted children: the Jamaican Study.
There is little unequivocal evidence that nutritional supplementation of undernourished children has a beneficial effect on their mental development. The effects of nutritional supplementation, with or without psychosocial stimulation, of growth-retarded (stunted) children aged 9-24 months were assessed in a study in Kingston, Jamaica. 129 children from poor neighbourhoods were randomly assigned to four groups--control, supplemented only, stimulated only, and supplemented plus stimulated. A group of matched non-stunted children (n = 32) was also included. The supplement comprised 1 kg milk-based formula per week for 2 years, and the stimulation weekly play sessions at home with a community health aide. The children's development (DQ) was assessed on the Griffiths mental development scales. Initially the stunted groups' DQs were lower than those of the non-stunted group, and those of the control group declined during the study, increasing their deficit. Stimulation and supplementation had significant independent beneficial effects on the children's development. Estimates of the supplementation effect ranged from 2.2 (95% confidence limits-1.4, 5.7) for the hand and eye subscale to 12.4 (5.4, 19.5) for the locomotor subscale and those for the stimulation effect from 6.4 (2.8, 10.0) for hand and eye to 10.3 (3.3, 17.3) for locomotor. The treatment effects were additive, and combined interventions were significantly more effective than either alone. These findings suggest that poor mental development in stunted children is at least partly attributable to undernutrition.
Female↗
Women's reasons for and barriers to seeking care for breast cancer symptoms.
Of note, these findings are based on women who did seek care for symptoms, rather than those who did not. However, the sample does include late care seekers; 23% of participants sought care after 3 months, and 3.6% waited more than a year. Delay often is defined as seeking care 3 months after symptoms are noted. Community health workers, such as public health nurses, may be able to document barriers among women who have symptoms but have not sought care. In this sample of predominantly low-income, minimally educated participants, women were motivated to seek care for their breast symptoms to obtain consultations and diagnoses, as well as to deal with their concerns about their symptoms and possible cancer diagnoses. Clinicians can recognize women's need to know the meaning of their symptoms, providing clarification as soon as possible and reassurance as appropriate. Clinicians and families can affirm that making time for women's symptom evaluations is a priority. Knowing that women's common barriers to accessing the health care system involve financial, time, and logistical considerations can direct health care administrators' agendas. Administrators, clinicians, and women can work for changes in health policies to assure universal coverage for preventive services for all women.
Adult↗
Implementation of capecitabine (Xeloda) into a cancer centre: UK experience.
Switching patients from intravenous 5-FU/LV to oral capecitabine (Xeloda) for the treatment of metastatic colorectal cancer is associated with a reduction in the need for hospitalisations to manage 5-FU-associated delivery and complications, with resulting healthcare savings. However, implementing oral therapy with capecitabine within a cancer centre in the UK has required a considerable change in attitude within healthcare services. The resulting need for patients to take an active role in their treatment, and the co-ordination and monitoring of such a service at home has raised issues for chemotherapy services. To enhance patient involvement and compliance with medication a patient guide was developed to educate, and support individuals and enable them to understand the rationale for treatment and when to seek help. In addition, patients are encouraged to monitor and record symptoms in a diary. This change in service focus has required an investment in time educating and informing patients, community health workers and hospital practitioners. This change has been co-ordinated through the chemotherapy outpatient clinic. Effective communication between hospital and home has been important in implementing oral chemotherapy. While the initial challenge of monitoring and educating patients receiving capecitabine has been met, the Primary Care team and cancer centre need to continue to assess side effects and patient compliance in order to improve knowledge of capecitabine among healthcare professionals and ensure safe practice.
Administration, Oral↗
Screening methods for childhood hearing impairment in rural Bangladesh.
OBJECTIVE: The purpose of this study was to determine a feasible strategy for screening young children in rural Bangladesh for hearing impairments. METHODS: Trained community health workers (CHWs) screened 4003 children between the ages of 2 and 9 years using conditioned play audiometry (CPA) and a subset of 569 of these children (ages 2-5 years), using physiologic (otoacoustic emissions [OAEs] and tympanometry). Measures of frequency and cross-tabulations are presented to describe results. RESULTS: Hearing screening using CPA was feasible for most children in the 6-9 years age range, but not for the younger children due to shyness and lack of cooperation. More than two thirds of the younger children were untestable on CPA. In response to this limitation, OAEs and tympanometry, requiring less cooperation on the part of the child, was implemented for a sample of younger children. Of the 569 children who received both CPA and OAE/tympanometry, 69% were untestable using CPA and 8.9% were untestable using OAE and tympanometry. CONCLUSIONS: These results suggest that hearing screening using CPA for older (6-9 years) and OAE/tympanometry for younger (2-5 years) children is feasible. Using the physiologic measures of OAE/tympanometry significantly reduced the number of untestable children, resulting in fewer referrals for diagnostic assessments. Thus, if only one methodology could be implemented, physiologic measure would be preferred. This is important because trained audiologists are scarce in Bangladesh. Technology is available and feasible for hearing screening in developing countries. Focus needs now to center on increasing the number of trained audiologists in developing countries to ensure better follow-up and accessibility to audiological services.
Acoustic Impedance Tests↗
Surgical and psychosocial outcomes in the rural injured--a follow-up study of the 2001 earthquake victims.
INTRODUCTION: After a major disaster in a developing country, the graphic media coverage of the dead and injured invariably leads to an influx of volunteering healthcare personnel to the disaster zone. Very few studies document the outcomes of the treatment rendered in this field setting, under compromised conditions. We revisited the rural victims of the 2001 Gujarat earthquake in an attempt to analyse their surgical outcome and the status of their physical/psychosocial rehabilitation, 2 years after the disaster. METHOD: We traced displaced victims treated for earthquake-related injuries to their new homes. A community health worker interviewed patients with an oral questionnaire in the local language about injuries, the examining physician and first aid, orthopaedic implants, amputations, wounds, disability, deformity, residual pain, occupational and economic rehabilitation, post traumatic stress disorder (PTSD) and perceptions of healthcare rendered. RESULTS: We located 133 of the 179 non-urban victims, from 11 villages. There were 10% missed injuries, 19% infection rate, restricted range of motion in 12%, non-union rate in 23% and reoperations in 30.5% patients. Fifty-one percent had resumed their previous occupation, but only 30% had recovered economically. Of 98% who had destroyed homes, 89% had their homes rebuilt. Residual sadness was the only significant PTSD symptom. CONCLUSION: This trauma outcome study highlights the shortcomings of surgeons for disaster-related work. One-tenth of the injuries were missed, suggesting that field examination at the site of disaster was more difficult than in the comfort of the hospital emergency room. Further there were inappropriately timed, aggressive implant operations, short time commitments, a lack of follow-up and a high rate of reoperations contributing to subsequent morbidity. These pointed to a need for training in disaster medicine within the curriculum of surgical residency. On the brighter side, despite poor sterility, prolonged transport times and no prehospital care, the postoperative infection rate was lower than expected. This perhaps was due to use of potent antibiotics in a previously unexposed rural population. Good physiotherapy given in the temporary shelters, by the informal carers within the family and by voluntary groups, kept up a good range of motion and reduced the final disability. PTSD was marked 3-6 months after the event, but was minimal 2 years postquake. Sadness about the event was the only residual PTSD symptom. While there were varying perceptions of satisfactory outcome, we found good coping mechanisms in place. The simple village folks were largely happy to be alive and accepted the residual deformities and cosmetic blemishes as a "small price to pay".
Adolescent↗
Using community-partnered participatory research to address health disparities in a Latino community.
Working in collaborative partnership with communities experiencing health disparities has been identified as a successful strategy to address population health disparities. This article illustrates a collaborative outreach program designed to address health disparities in a poor Latino community in Los Angeles County, California, by training community members to function as lay health advisors (LHAs) to provide health education to members of their own community. The study consisted of three phases, each accomplished in a collaborative partnership among researchers, community residents, community-based organizations, and health officials. In Phase 1, a community needs assessment was conducted to identify a community with demonstrated health disparities and agencies within that community willing to become partners in providing health education. In Phase 2, community members were recruited and trained to function as LHAs. Phase 3 consisted of implementation of community outreach and education activities by the LHAs in their community. This article describes how the study changed over time through responding to challenges that arose in the process of conducting the project, the participatory or collaborative methods used, and feedback received. Strategies for successful research using community partners are presented and implications discussed for future research efforts using community-partnered participatory methods for reducing health disparities.
Community Health Workers↗
Rationales for home safety promotion in the Iranian primary healthcare system: results from a pilot study.
OBJECTIVE: To analyse the prerequisites for a nationwide primary healthcare (PHC) home safety promotion programme in Iran. BACKGROUND: Injury is a major public health problem throughout the world, currently accounting for one-seventh of all premature deaths and disabilities. Within 20 years, it is estimated that the proportion will increase to one-fifth. The present healthcare system in Iran was started in 1979, with a major focus on easy access to services and prevention. The system is based on the 'health house', which is run by community health workers. A survey shows that 36% of injuries occur in the home environment. A pilot phase of the Home Safety Promotion Programme was initiated in 1994, and included safety checking at home for fences, kitchens, drugs and poisons, heaters, electricity, and stairs and ladders. The pilot study covered 478,551 households out of the 12 million (approximately) in Iran. Sixty-nine supervisors were involved individually, assembled into eight focus groups. RESULTS: Household safety increased by 10-20% over the 4 years of the study. The frequency of home visits changed from annual to seasonal, since all participants agreed that there were seasonal differences in safety problems. The supervisors showed a high level of knowledge of injury as a public health problem, and also positive attitudes towards doing something about safety on the basis of a PHC scheme. The role of a surveillance system was highlighted, and it was suggested that such a system should be added to the programme. DISCUSSION AND CONCLUSION: Based on our preliminary findings, there were reasons to obtain a policy decision concerning a national programme for safety promotion before extending the pilot scheme to the whole country. A national safety programme was decided upon following completion of the pilot study. It includes a home-related-injury surveillance system that is mandatory in rural areas and voluntary in some cities.
Accidents, Home↗
Regionalized perinatal care in developing countries.
Neonatal-perinatal ill health and mortality are overwhelmingly a burden of the developing world. As many as 90% of births, 98% of fetal deaths and 98% of neonatal deaths occur in less developed countries. Regionalized perinatal services were introduced in developed countries when most neonatal mortality was confined to very-low-birthweight babies who required intensive perinatal care to survive. A large proportion of newborn morbidity and mortality in developing countries, however, continues to occur among full-term and moderate-sized low-birthweight neonates who can be managed well in the community and at small hospitals. The model of regionalized perinatal care as practiced in developed countries is, at present, neither affordable nor relevant to the needs of many developing countries. It is possible to achieve considerably lower neonatal mortality rates in resource-poor settings by implementing home-based newborn care delivered by community health workers, and by promoting institutional perinatal care at simple facilities provided by trained midwives.
Developing Countries↗
Individual and district scale determinants of users' satisfaction with primary health care in developing countries.
The paper has two aims: to explore possible determinants of user satisfaction based on a broad conception of the health care system involving both individual and district scale variables, and to add to the limited knowledge and empirical study about such determinants in developing countries. The study was carried out in one of Brazil's poorest states, Ceará, in the northeast of the country. Brazil has a policy of an increased role for the population in management together with decentralised management to the local administrative (municipio) scale. For user views on health care to be useful in management, understanding their determinants needs to explore not only individual scale factors but also influences from the local health system and wider society, here termed district scale factors. The study design took different angles on users' satisfaction to build three measures: the particular health event (termed perceived quality); a generalised perception (termed satisfaction); and, satisfaction with the Community Health Worker (termed CHW satisfaction). Potential determinants explored at the individual scale (17 variables) are grouped into: socio-demographic and economic characteristics; health outcome; health care provision; and, awareness of space for local voice in planning. Potential determinants explored at the district scale (50 variables) are grouped into: formal organisation and management (health system inputs, management capacity, outputs and outcomes); informal organisation (population awareness of health system activities, staff characteristics, district management style); and, local political culture (geographic and socio-economic population profile, commitment to the district of local leaders, norms and values of staff regarding practice). Three determinants were key for all three user evaluation measures: getting an appointment, getting better, and the type of district (rural-urban). Our primary conclusion from this study is that there are limitations to the extent that user satisfaction can fulfill the claims made for it. On a more positive note, with these limitations noted, user satisfaction can prove a useful management tool more modestly at a local, context-specific scale.
Brazil↗
Inequities in healthcare seeking in the treatment of communicable endemic diseases in Southeast Nigeria.
This paper investigates the socio-economic inequities in healthcare seeking in the treatment of common communicable endemic diseases, with an emphasis on the use of primary health care (PHC) centres, where most endemic disease control activities take place. A questionnaire was used to collect information on occurrence of diseases and healthcare seeking from randomly selected households in four local government areas in Southeast Nigeria. Principal components analysis was used to create a socio-economic status (SES) index, which was divided into quartiles. The ratio of the values for the poorest quartile to that of the least poor quartile (bottom/top quartile) together with concentration indices for the variables under consideration was used as the measures of inequity. Logistic analysis was used to examine the determinants of use of PHC centres. The poorest quartile was more likely to use low-level providers (patent medicine dealers, shops, herbalists) and least likely to use the PHC centres. The concentration indices were -0.10, -0.06, -0.37, 0.11 and 0.04 for the use of herbalists, patent medicine dealers, community-health workers, PHC centres and hospitals, respectively. Also, the poorest quartile was more likely to lose person-days when ill. Logistic analysis showed that SES, availability of good services, proximity of the centres to the homes and polite health workers increased the use of the PHC centres. As such, improvement of quality of PHC services and improved geographic access could increase the overall use of PHC centres. Furthermore, in the long-term, a decrease in the amount of user fees, enhanced physical access and improved quality of services could decrease inequity in use of PHC centres and hospitals in the treatment of endemic diseases. The bottom/top quartile ratios and concentration indices produced similar results and hence both methods hence complement each other.
Adult↗
Antimalarials dispensing pattern by patent medicine dealers in rural settlements in Nigeria.
The pattern of antimalarial dispensing by Patent Medicine Dealers (PMD) was studied in 17 villages of Gokana (Ogoni Land) in Rivers State of Nigeria. Of the 40 PMDs studied only eight (20%) had had formal health training and only eight could understand doctor's prescriptions. In total, 19 different types of antimalarials could be obtained from the individual ranges of antimalarials displayed by the 40 PMDs in the study. Chloroquine phosphate was the most frequently available. Twenty-three (57.5%) of PMDs administered Chloroquine at below the recommended dose of this drug. Twelve (30%) PMDs, eight with formal training and four others, administered the correct dose whilst five (12.5%) gave too much. All 40 of the PMDs studied knew how to dispense Daraprim and Fansidar correctly. We conclude that malaria control through prevention and treatment would be more effective if PMDs were to receive training on antimalarial dispensing alongside Community Health Workers.
Antimalarials↗
Factors associated with safe preparation and home use of sugar-salt solution.
The use of oral rehydration salts is frustratingly low, mostly because one must visit a health care provider to procure the packets. Mothers are advised to use sugar-salt solution (SSS) and other home-based fluids as first fluid replacement during diarrhoea. However, the use rate of SSS is also not encouraging and few mothers can prepare it correctly. We conducted an observation study on mothers who reported to the diarrhoea treatment centre of the International Centre for Diarrhoeal Disease Research, Bangladesh during September 1990 through to December 1992. At quarterly intervals, 240 mothers were recruited randomly to elicit their knowledge and ability to prepare SSS. Most (94.6%) of the mothers knew about the solution, but only 62% of them used the solution at home. The use rate was higher when mothers came to know about the solution through interpersonal communication (e.g. community health workers, doctors, friends, neighbours and relatives) and from multiple sources (72%) than when they learned about it from the media or from a single source (54%). As many as 85.4% of the mothers could prepare the solution within the safe limits of sodium concentrations (30 to 100 mmol/l). The figure rose to 95.8% after practical instruction as to how to prepare the solution. This improvement was dependent neither on the literacy level of mothers nor on their knowledge and use of the solution earlier. To increase interpersonal communication and to improve mothers' behaviour in using and correctly preparing SSS, every contact with health care providers should be utilised for organising sessions on the use and preparation of the solution.
Bangladesh↗
Screening clinical breast examination.
Evidence suggests that CBE detects most breast cancers found by mammograms, and also some that mammograms miss, particularly in younger women. Recent estimates suggest that screening CBE has a sensitivity of about 54% and a specificity of about 94%. Yet, the impact of screening CBE on breast cancer mortality is still not clear, as there are no trials that have reported results comparing screening CBE alone to no screening. In some countries, the costs of screening mammography are considered too high, and policy makers are considering implementing screening programs based on CBE rather than mammography. In those countries with screening mammography programs already in place, screening CBE should also be included, as this will increase the overall sensitivity of breast cancer screening. Studies have shown that community health workers can be trained to conduct screening CBE, and that trained nurses perform CBE as well as physicians. Physicians should take on the responsibility to ensure that screening CBE is performed properly, however, and that it remains an integral part of all screening mammography programs.
Adult↗
Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomised trial.
BACKGROUND: No satisfactory strategy for reducing high child mortality from malaria has yet been established in tropical Africa. We compared the effect on under-5 mortality of teaching mothers to promptly provide antimalarials to their sick children at home, with the present community health worker approach. METHODS: Of 37 tabias (cluster of villages) in two districts with hyperendemic to holoendemic malaria, tabias reported to have the highest malaria morbidity were selected. A census was done which included a maternity history to determine under-5 mortality. Tabias (population 70,506) were paired according to under-5 mortality rates. One tabia from each pair was allocated by random number to an intervention group and the other was allocated to the control group. In the intervention tabias, mother coordinators were trained to teach other local mothers to recognise symptoms of malaria in their children and to promptly give chloroquine. In both intervention and control tabias, all births and deaths of under-5s were recorded monthly. FINDINGS: From January to December 1997, 190 of 6383 (29.8 per 1000) children under-5 died in the intervention tabias compared with 366 of 7294 (50.2 per 1000) in the control tabias. Under-5 mortality was reduced by 40% in the intervention localities (95% CI from 29.2-50.6; paired t test, p<0.003). For every third child who died, a structured verbal autopsy was undertaken to ascribe cause of mortality as consistent with malaria or possible malaria, or not consistent with malaria. Of the 190 verbal autopsies, 13 (19%) of 70 in the intervention tabias were consistent with possible malaria compared with 68 (57%) of 120 in the control tabias. INTERPRETATION: A major reduction in under-5 mortality can be achieved in holoendemic malaria areas through training local mother coordinators to teach mothers to give under-5 children antimalarial drugs.
Antimalarials↗
The looming threat of AIDS and HIV in Latin America.
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Acquired Immunodeficiency Syndrome↗