Surveillance system integration: reporting the results of a global multicountry survey

OBJECTIVES

Currently, there is no comprehensive picture of the global surveillance landscape. This survey examines the current state of surveillance systems, levels of integration, barriers and opportunities for the integration of surveillance systems at the country level, and the role of national public health institutes (NPHIs).

STUDY DESIGN

This was a cross-sectional survey of NPHIs.

METHODS

A web-based survey questionnaire was disseminated to 110 NPHIs in 95 countries between July and August 2022. Data were descriptively analysed, stratified by World Health Organization region, World Bank Income Group, and self-reported Integrated Disease Surveillance (IDS) maturity status.

RESULTS

Sixty-five NPHIs responded. Systems exist to monitor notifiable diseases and vaccination coverage, but less so for private, pharmaceutical, and food safety sectors. While Ministries of Health usually lead surveillance, in many countries, NPHIs are also involved. Most countries report having partially developed IDS. Surveillance data are frequently inaccessible to the lead public health agency and seldomly integrated into a national public health surveillance system. Common challenges to establishing IDS include information technology system issues, financial constraints, data sharing and ownership limitations, workforce capacity gaps, and data availability.

CONCLUSIONS

Public health surveillance systems across the globe, although built on similar principles, are at different levels of maturity but face similar developmental challenges. Leadership, ownership and governance, supporting legal mandates and regulations, as well as adherence to mandates, and enforcement of regulations are critical components of effective surveillance. In many countries, NPHIs play a significant role in integrated disease surveillance.

A review of health education activities targeting schoolchildren for the control of soil-transmitted helminthiasis in Southeast Asia, with emphasis upon the Magic Glasses approach

Soil-transmitted helminths continue to be a serious problem causing disease and morbidity globally. Children, mostly school-aged, are more at risk of these infections. The main strategy for control remains to be the mass drug administration (MDA) of antihelminthic drugs. With the limitation of MDA to prevent re-infection, the need for additional approaches such as hygiene education and improvements in water, sanitation and hygiene (WASH) infrastructure are required. Although the importance of health education as a crucial component of an integrated approaches to STH control is highlighted, this component has often been disregarded because the other more complex solutions have been the focus of most studies and programmes. We performed literature searches from four bibliographic databases - Scopus, PubMed, Web of Science and Cochrane Library - to determine availability of studies on the impact of health education interventions targeting STH infections on schoolchildren in Southeast Asia. Our review found only three studies that evaluated health education interventions targeting children. The current lack of evidence in this area suggests the need for more studies assessing the impact of health education intervention for STH control. A successful health education programme for STH called "The Magic Glasses" has been developed targeting schoolchildren in China and the Philippines. This public health intervention displayed significant impact in terms of improving knowledge, attitude and practices, reducing prevalence of STH infections in schoolchildren and encouraging compliance to MDA. This article details the successes and benefits of the Magic Glasses programme as a promising control tool for STH in the Southeast Asian region.

Cost analysis for "The Magic Glasses Philippines" health education package to prevent intestinal worm infections among Filipino schoolchildren

BACKGROUND

Soil-transmitted helminth (STH) infections are a significant public health problem affecting over 900 million people globally. Health education has been shown to complement mass drug administration (MDA) for the control of these intestinal worms. We reported recently results of a cluster randomised control trial (RCT) showing the positive impact of the "The Magic Glasses Philippines (MGP)" health education package in reducing STH infections among schoolchildren in intervention schools with ≤15% STH baseline prevalence in Laguna province, the Philippines. To inform decision making on the economic implications of the MGP, we evaluated the in-trial costs and then quantified the costs of scaling up the intervention both regionally and nationally.

METHODS

Costs were determined for the MGP RCT conducted in 40 schools in Laguna province. We estimated the total cost and the costs incurred per student for the actual RCT and the total costs for regional and national scale-up in all schools regardless of STH endemicity. The costs associated with the implementation of standard health education (SHE) activities and mass drug administration (MDA) were determined with a public sector perspective.

FINDINGS

The cost per participating student in the MGP RCT was Php 58.65 (USD 1.15) but if teachers instead of research staff had been involved, the estimated cost would have been considerably lower at Php 39.45 (USD 0.77). Extrapolating the costs for regional scale-up, the costs per student were estimated to be Php 15.24 (USD 0.30). As it is scaled up at the national level to include more schoolchildren, the estimated cost was increased at Php 17.46 (USD 0.34). In scenario 2 and 3, consistently, labour/salary costs associated with the delivery of the MGP contributed most to overall programme expenditure. Furthermore, the estimated average cost per student for SHE and MDA were Php 117.34 (USD 2.30) and Php 58.17 (USD 1.14), respectively. Using national scale up estimates, the cost of combining the MGP with SHE and MDA was Php 192.97 (USD 3.79).

INTERPRETATION

These findings suggest that the integration of MGP into the school curriculum would be an affordable and scalable approach to respond to the continuous burden of STH infection among schoolchildren in the Philippines.

FUNDING

National and Medical Research Council, Australia, and the UBS-Optimus Foundation, Switzerland.

Model validation for a knowledge and practices survey towards prevention of soil-transmitted helminth infections in rural villages in Indonesia

The rate of soil-transmitted helminth (STH) infection is estimated to be around 20% in Indonesia. Health promotion and health education are cost-effective strategies to supplement STH prevention and control programs. Existing studies suggest that quantitative tools for knowledge, attitudes and practices (KAP) are important to monitor effective community-based STH interventions. However, evidence is limited regarding the applicability of such tools. This study aims to identify the socio-demographic predictors for STH-related knowledge and practices and validate the quantitative tools in population use. A cross-sectional study design was conducted among residents of 16 villages in Central Java, Indonesia. Adult and child respondents were interviewed to assess general knowledge and practices in relation to STH. Two mixed effects models identified the significant factors in predicting knowledge and practice scores. The model predicted knowledge and practice scores were compared with the observed scores to validate the quantitative measurements developed in this study. Participants' socio-demographic variables were significant in predicting an individual's STH-related knowledge level and their hand washing and hygiene practices, taking into account household-level variability. Model validation results confirmed that the quantitative measurement tools were suitable for assessing STH associated knowledge and behaviour. The questionnaire developed in this study can be used to support school- and community-based health education interventions to maximize the effect of STH prevention and control programs.

Increasing role of Public Health Rapid Response Teams in infectious disease outbreaks

Background

Following the Ebola crisis (2013-2016), the WHO, Global Health Security Agenda and other international actors advocated for the development of Public Health Rapid Response Teams (RRTs) to strengthen outbreak response. Despite significant investment, evidence on the uptake, composition and effectiveness of such teams remains lacking.

Methods

Qualitative review of published and grey literature including from governmental and multilateral agencies, with semi-structured interviews of key informants. Thematic content analysis was completed and evidence synthesised to inform future policy recommendations.

Results

RRTs have been adopted globally providing surge capacity in outbreak settings. RRTs typically include microbiologists and field epidemiologists but can be more efficacious when broadly multidisciplinary with the inclusion of social scientists, risk communicators and infection prevention and control professionals. The organisation of RRTs must be responsive to district and national contexts so existing systems are not undermined, with regional collaboration beneficial where skill gaps exist. Literature and interviewees agreed that RRTs should not be uniformly defined by narrow technical capabilities, but rather regional standards and evaluation of deployments used to assess operational readiness.

Conclusions

Public Health RRTs should be multiprofessional in nature and evaluated against regional standards to be effective. Future research should seek to assess the experience of countries before and after RRT implementation including detailed economic assessment.

Key messages

"The Magic Glasses Philippines": a cluster randomised controlled trial of a health education package for the prevention of intestinal worm infections in schoolchildren

Background

Soil-transmitted helminths (STH) cause substantial disease and disability globally. Health education has proven complementary to school-based drug administration programs for STH control. We determined the generalizability of the impact of "The Magic Glasses" health education package for STH prevention in schoolchildren in Laguna province, the Philippines, having previously shown its positive impact in China.

Methods

We conducted a cluster-randomised controlled trial, in schoolchildren, aged 9-10 years, across 40 schools over one year. Schools were randomly assigned either to the "Magic Glasses Philippines" health education intervention package (consisting of a cartoon video, classroom discussions, drawing and essay competition) complementing the standard health education activities of the Philippines Departments of Health and Education, or to a control group, which involved only the standard health education activities. The primary trial outcomes were the proportion of STH infected schoolchildren and their knowledge, attitude and behaviour of STH assessed in both groups at baseline and through two follow-up surveys undertaken immediately prior to the semi-annual national mass administration of albendazole. The outcomes between the study arms were compared using generalized estimating equation models, accounting for clustering at the school level. The trial is registered with Australian New Zealand Clinical Trials Registry number: ACTRN12616000508471.

Findings

At follow-up assessments, the mean knowledge and behaviour scores in the intervention group were, respectively, 5·3 (95% confidence interval [CI]:4·2-6·5; p=<0.001) and 1·1 (95% CI: 0·4-1·7; p=0.002) percentage points higher than the control group. There was no overall effect on helminth infections (any STH; adjusted odds ratio [aOR]:1·0; 95% CI: 0·8-1·3; p=0·856), Ascaris lumbricoides; aOR:1·0; 95% CI: 0·7-1·6; p=0·894, or Trichuris trichiura; aOR:1·7; 95% CI: 0·9-1·6; p=0·315) but sub-group analysis showed a 60% reduction in the odds of any STH infection resulting from the "Magic Glasses" intervention in schools with a baseline prevalence ≤15% (aOR: 0·4; 95% CI: 0·2-0·7; p=0·001).

Interpretation

The health-education package demonstrated a modest but statistically significant impact on the students' overall STH knowledge and changes in their behaviour but was only effective in preventing STH infections in intervention schools where the baseline prevalence was ≤15%.

Funding

National Health and Medical Research Council, Australia, and the UBS-Optimus Foundation, Switzerland.

Soil-transmitted helminth infections and nutritional indices among Filipino schoolchildren

BACKGROUND

Soil-transmitted helminth (STH) infections are still prevalent among schoolchildren in the Philippines. We evaluated the risk factors associated with STH and the relationship between STH and nutritional indices among schoolchildren aged 9-10 years in Laguna province, the Philippines.

METHODS

We used the baseline data from 40 schools enrolled in a randomised controlled trial of the Magic Glasses Philippines health education package. Data on demographic and socio-economic variables, and STH related knowledge, attitudes and practices, were obtained through a questionnaire. Stool samples were collected and assessed for STH egg presence using the Kato-Katz technique. Haemoglobin levels and height and weight of study participants were also determined. The generalized estimating equations approach was used to construct logistic regression models to assess STH-associated risk factors, and the association between any STH infection and anaemia, child stunting, wasting and being underweight. The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616000508471).

FINDINGS

Among 1,689 schoolchildren, the prevalence of any STH was 23%. The prevalence of anaemia, stunting, being underweight and wasting was 13%, 20.2%, 19% and 9.5%, respectively. Age, socio-economic status, rural/urban classification of schools and knowledge of STH were significant risk factors for acquiring a STH infection. Moreover, infections with any STH were significantly associated with stunting (P = <0.001) and being underweight (P = <0.003), but not wasting (P = 0.375) or anaemia (P = 0.462) after controlling for confounding covariates.

CONCLUSION

The study findings emphasise the need for sustainable deworming in tandem with other measures such as the provision of health education, improvements in sanitation and hygiene, and nutritional programs in order to control STH infections and improve morbidity outcomes in schoolchildren.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12616000508471).

Group singing improves quality of life for people with Parkinson's: an international study

Objectives: Group singing has been reported to enhance quality of life (QoL) and mental health in older people. This paper explored whether there are differences in the effects of group singing intervention on people with Parkinson's (PwPs) in Australia, UK and South Korea.Methods: The study included PwPs (N = 95; mean age = 70.26; male 45%) who participated in a standardised 6-month weekly group singing programme. Parkinson's health-related QoL measure (PDQ39) and mental health assessment (DASS) were administered at baseline and follow-up. ANOVAs were performed with significance set as p < .05.Results: ANOVAs revealed main effects of Time on the Stigma and Social Support subscales of PDQ39; both showed a small but significant improvement over time. However, the social support reduction was moderated by country; social support was improved only in South Korean participants. The reduction in stigma was greater than previously reported minimal clinically important differences, as was the social support reduction in South Korean participants. In terms of mental health, ANOVAs revealed that the scores of Anxiety and Stress domains of DASS significantly decreased from pre-test to post-test with small effect sizes.Conclusion: This first international singing study with PwPs demonstrated that group singing can reduce stigma, anxiety and stress and enhance social support in older adults living with Parkinson's. The findings are encouraging and warrant further research using more robust designs.

Epidemiology of soil-transmitted helminth infections in Semarang, Central Java, Indonesia

Soil-transmitted helminth (STH) infections are endemic in Indonesia. However, prevalence data for many parts of the country are incomplete. The aim of this study was to determine human STH prevalence and knowledge and practices relating to STH risk behaviour, to provide a current view of the status of STH infection in rural communities in Central Java. A cross-sectional survey of 16 villages was conducted in Semarang, Central Java in 2015. Demographic and household data together with information about knowledge and practices relating to STH and hygiene were elicited through face-to-face interviews. Stool samples were collected and examined using the flotation method. Children (aged 2–12 years) also had their haemoglobin (Hb) levels, height and weight data collected, and BMI estimated. Data were analysed using univariate logistic regression analysis. A total of 6,466 individuals with a mean age of 33.5 years (range: 2–93) from 2,195 households were interviewed. The overall prevalence of STH was 33.8% with Ascaris lumbricoides (roundworm) the predominant nematode identified (prevalence = 26.0%). Hookworm and Trichuris trichiura (whipworm) were found in 7.9% and 1.8% of participants, respectively. Females were at increased odds of infection with A. lumbricoides (adjusted OR 1.14, 95% CI [1.02–1.29], p = 0.02). Adults in age groups 51–60 and over 60 years had the highest odds of being infected with hookworm (adjusted OR 3.01, 95% CI [1.84–4.91], p<0.001 and adjusted OR 3.79, 95% CI [2.30–6.26], p<0.001, respectively) compared to 6–12 year olds. Farmers also had higher odds of being infected with hookworm (adjusted OR 2.36, 95% CI [1.17–4.76], p = 0.02) compared to other occupation categories. Poverty (OR 2.14, 95% CI [1.77–2.58], p<0.001), overcrowding (OR 1.35, 95% CI [1.27–1.44], p<0.001), goat ownership (OR 1.61, 95% CI [1.10–2.41], p = 0.02) and the presence of dry floor space in the home (OR 0.73, 95% CI [0.58–0.91], p = 0.01) were all household factors significantly associated with an increased odds of infection. Infection with STH was not significantly associated with the gastrointestinal illness (p>0.05), BMI or Hb levels; however, one third of all 2–12 year olds surveyed were found to be anaemic (i.e. Hb concentrations below 110g/l or 115g/l for children under 5 and 5 years or older, respectively), with a greater proportion of school-age children at risk. Knowledge and behaviour related to hygiene and gastrointestinal diseases varied widely and were generally not associated with STH infection. The study revealed that STH infection remains endemic in Central Java despite ongoing deworming programs. Current control efforts would benefit from being re-evaluated to determine a more effective way forward.

Among the major NTDs, STH are one of the most common disabling chronic infections. Currently available drug treatments, whilst considered safe and generally well tolerated, do not confer protection against new infections. In Indonesia, prevalences of STH of up to 90% have been reported but these estimates are based on data from the 1980s and 90s. More up-to-date STH prevalence estimates are urgently needed to help guide future control efforts.

A cross-sectional survey was conducted in rural villages in Semarang, Central Java to determine human STH prevalence and associated risk factors. One-third of all cohort participants were positive for STH with prevalences of 26%, 7.9% and 1.8% identified for Ascaris lumbricoides, hookworm and Trichuris trichiura at 7.9% and 1.8%, respectively. Risk of A. lumbricoides infection was higher for females, whilst farmers and adults over 50 had an increased risk of hookworm infection. Poverty, overcrowding in the home and goat ownership were also associated with an increased risk at the household level.

Soil-transmitted helminthiases remains a significant health problem in Central Java, Indonesia, exacerbated by limited knowledge about STH, poor sanitation and hygiene and poverty prevalent in the region. Control efforts would benefit from an integrated approach emphasising WASH, health education and chemotherapy. Further studies investigating environmental contamination with STH in and around homes in endemic areas could provide further insight into links between household factors and STH identified in our study.

Determining the Impact of a School-Based Health Education Package for Prevention of Intestinal Worm Infections in the Philippines: Protocol for a Cluster Randomized Intervention Trial

Background

Repeated mass drug administration (MDA) of antihelminthics to at-risk populations is still the main strategy for the control of soil-transmitted helminth (STH) infections. However, MDA, as a stand-alone intervention, does not prevent reinfection. Accordingly, complementary measures to prevent STH reinfection, such as health education and improved sanitation, as part of an integrated control approach, are required to augment the effectiveness of MDA for optimal efficiency and sustainability.

Objective

The aim of this study is to determine the impact and generalizability of a school-based health education package entitled The Magic Glasses for STH prevention in the Philippines.

Methods

We conducted a cluster randomized controlled intervention trial, involving 2020 schoolchildren aged 9-10 years, in 40 schools in Laguna Province, Philippines, to evaluate the impact of the school-based health education package for the prevention of STHs. The trial was conducted over the course of 1 year (June 2016 to July 2017). A total of 20 schools were randomly assigned to the intervention arm, in which The Magic Glasses Philippines health education package was delivered with the standard health education activities endorsed by the Philippines Department of Health (DOH) and the Department of Education (DepEd). The other 20 schools comprised the control arm of the study, where the DOH/DepEd’s standard health education activities were done. At baseline, parasitological assessments and a knowledge, attitude, and practice survey were carried out in all schools. In addition, height, weight, and hemoglobin levels were obtained from each child (after parental consent), and their school attendance and academic performance in English and mathematics were accessed from the school records. The baseline and 2 follow-up surveys were completed using the same study measurements and quality-control assessments.

Results

Key results from this cluster randomized intervention trial will shed light on the impact that The Magic Glasses health education package will have against STH infections in schoolchildren in the province of Laguna, located on the Island of Luzon, in the Calabarzon Region of the Philippines.

Conclusions

The results of the trial will be used to assess the generalizability of the impact of The Magic Glasses health education package in different epidemiological and cultural settings, providing evidence for translation of this health education package into public health policy and practice in the Asian region and beyond.

Trial Registration

Australian New Zealand Clinical Trials Registry number ACTRN12616000508471; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368849

International Registered Report Identifier (IRRID)

DERR1-10.2196/18419

A systematic review on the effects of group singing on persistent pain in people with long-term health conditions

Background and Objectives

Singing can have a range of health benefits; this paper reviews the evidence of the effects of group singing for chronic pain in people with long‐term health conditions.

Database and Data Treatment

We searched for published peer‐reviewed singing studies reporting pain measures (intensity, interference and depression) using major electronic databases (last search date 31 July 2018). After screening 123 full texts, 13 studies met the inclusion criteria: five randomized controlled trials (RCTs), seven non‐RCTs and one qualitative study. Included studies were appraised using Downs and Black and the Critical Appraisals Skills Programme quality assessments.

Results

Included studies reported differences in the type of singing intervention, long‐term condition and pain measures. Due to the high heterogeneity, we conducted a narrative review. Singing interventions were found to reduce pain intensity in most studies, but there was more equivocal support for reducing pain interference and depression. Additionally, qualitative data synthesis identified three key linked and complementary themes: physical, psychological and social benefits.

Conclusion

Group singing appears to have the potential to reduce pain intensity, pain interference and depression; however, we conclude that there is only partial support for singing on some pain outcomes based on the limited available evidence of varied quality. Given the positive findings of qualitative studies, this review recommends that practitioners are encouraged to continue this work. More studies of better quality are needed. Future studies should adopt more robust methodology and report their singing intervention in details. Group singing may be an effective and safe approach for reducing persistent pain and depression in people with long‐term health conditions.

Significance

This systematic review assesses research evidence for the effectiveness of group singing on chronic pain in people with long‐term health conditions. Narrative syntheses revealed that there is partial support for singing effects on some pain outcomes based on the limited available evidence of varied quality. Qualitative data provided additional support of physical, psychological and social benefits. The review highlights implications for practice and future studies.

Group Singing Has Multiple Benefits in the Context of Chronic Pain: An Exploratory Pilot Study

AIMS

This paper reports findings of a pilot singing intervention to assist people living with chronic pain.

METHODS

Pain Management Clinic outpatients participated in 10 weekly group singing sessions. Benefits of the intervention and its impact on participants' (N = 4) experiences of pain were explored qualitatively.

RESULTS

Three main themes comprising over 20 separate codes indicated physical, psychological, and social dimensions associated with the intervention. People with chronic pain identify multiple benefits from participating in a group singing program.

CONCLUSIONS

Results indicate that group singing in chronic pain settings has multiple benefits and may positively complement clinical outcomes, serving as an effective adjunct to conventional pain management care and nursing.

Group Singing Has Multiple Benefits in the Context of Chronic Pain: An Exploratory Pilot Study

AIMS

This paper reports findings of a pilot singing intervention to assist people living with chronic pain.

METHODS

Pain Management Clinic outpatients participated in 10 weekly group singing sessions. Benefits of the intervention and its impact on participants' (N = 4) experiences of pain were explored qualitatively.

RESULTS

Three main themes comprising over 20 separate codes indicated physical, psychological, and social dimensions associated with the intervention. People with chronic pain identify multiple benefits from participating in a group singing program.

CONCLUSIONS

Results indicate that group singing in chronic pain settings has multiple benefits and may positively complement clinical outcomes, serving as an effective adjunct to conventional pain management care and nursing.

Shadow Puppets and Neglected Diseases: Evaluating a Health Promotion Performance in Rural Indonesia

'Rama and the Worm' is a shadow puppet production targeting neglected diseases in Central Java. It is an entertainment-based intervention study to promote health by reducing the impact of parasitic diseases such as soil-transmitted helminths (STH). The study uses traditional Javanese shadow puppetry (wayang kulit) as a vehicle in village communities to disseminate health messages and promote behaviour change to prevent diseases caused, primarily, by inadequate sanitation and poor hygiene. The health education messages contained in the play, although using traditional characters and themes, required the creation of a completely new narrative script, using characters and plot lines familiar to the wayang kulit repertoire, but placing them in new situations that relate specifically to health promotion objectives. The intervention was piloted in a village in Central Java, Indonesia using a pre/post design with both qualitative and quantitative analysis. A total of 96 male and female villagers, aged between 7 and 87 years, provided both baseline and follow up data. Participant knowledge and behaviours related to gastrointestinal and helminth-related disease were assessed before and after the intervention through a questionnaire administered by interview. Results revealed statistically significant improvements in both knowledge (48.6% pre-intervention score vs. 62.8% post-intervention score, p < 0.001) and behaviour (77.4% vs. 80.6%, p = 0.004) related to gastrointestinal and helminth disease. Findings of the study indicate the wayang kulit performance is an effective health education tool. The results provide proof of concept with scaling up the next step forward. The wayang kulit production provides a significant additional component for an integrated, comprehensive approach to reduction and elimination of STH infection.

Measuring and monitoring equity in access to deceased donor kidney transplantation

The Organ Procurement and Transplantation Network monitors progress toward strategic goals such as increasing the number of transplants and improving waitlisted patient, living donor, and transplant recipient outcomes. However, a methodology for assessing system performance in providing equity in access to transplants was lacking. We present a novel approach for quantifying the degree of disparity in access to deceased donor kidney transplants among waitlisted patients and determine which factors are most associated with disparities. A Poisson rate regression model was built for each of 29 quarterly, period-prevalent cohorts (January 1, 2010-March 31, 2017; 5 years pre-kidney allocation system [KAS], 2 years post-KAS) of active kidney waiting list registrations. Inequity was quantified as the outlier-robust standard deviation (SD_w ) of predicted transplant rates (log scale) among registrations, after "discounting" for intentional, policy-induced disparities (eg, pediatric priority) by holding such factors constant. The overall SD_w declined by 40% after KAS implementation, suggesting substantially increased equity. Risk-adjusted, factor-specific disparities were measured with the SD_w after holding all other factors constant. Disparities associated with calculated panel-reactive antibodies decreased sharply. Donor service area was the factor most associated with access disparities post-KAS. This methodology will help the transplant community evaluate tradeoffs between equity and utility-centric goals when considering new policies and help monitor equity in access as policies change.

New Insights Into the Alleged Kidney Donor Profile Index Labeling Effect on Kidney Utilization

The Kidney Donor Profile Index (KDPI) became a driving factor in deceased donor kidney allocation on December 4, 2014, with the implementation of the kidney allocation system (KAS). On April 20, 2016, the annual recalibration of the Kidney Donor Risk Index into KDPI was incorrectly programmed in DonorNet, resulting in erroneously high KDPI values, by between 1 and 21 percentage points (e.g. actual KDPI of 70% was displayed as 86%). The error was corrected on May 19, 2016, <24 h after being recognized. During this 30-day period, the distribution of recipients largely resembled pre-KAS patterns. The observed discard rate of 22.9% was higher than the post-KAS average of 19.6% (odds ratio [OR]: 1.22) but far lower than the projected rate of 31.4% (OR: 1.96) based on the usual discard rate by KDPI relationship, suggesting clinicians and patients did not rely heavily on this single number (KDPI) in kidney-utilization decisions. Still, risk-adjusted analyses suggest the elevated discard rate was most likely attributable to the erroneously high KDPIs, not a shift in donor characteristics or random chance. The rise in discard rate was sharply higher for kidneys with inflated KDPI that crossed the 85% policy threshold (OR: 1.46; p = 0.049) versus those that did not (OR: 1.06; p = 0.631).

The Impact of the New Kidney Allocation System on Prior Living Kidney Donors' Access to Deceased Donor Kidney Transplants: An Early Look

This study investigated the early effects of the new kidney allocation system (KAS) on the access of prior living kidney donors (PLDs) to deceased donor kidney transplants. Using data from the Organ Procurement and Transplantation Network, we compared prevalent and incident cohorts of PLDs in the 1-year periods before and after KAS implementation (pre-KAS group: December 4, 2013, to December 3, 2014, n = 50 [newly listed PLDs]; post-KAS group: December 4, 2014, to December 3, 2015, n = 39). We assessed transplant rates per active patient-year, waiting times, and Kidney Donor Profile Index (KDPI) of transplanted kidneys. Transplant rates were not statistically different before and after KAS implementation for either prevalent (2.37 vs. 2.29, relative risk [RR] 0.96; 95% confidence interval [CI] 0.62-1.49) or incident (4.76 vs. 4.36, RR 0.92; 95% CI 0.53-1.60) candidates. Median waiting time (MWT) to deceased donor kidney transplant for prevalent PLDs in the post-KAS cohort was 102.6 days compared with 82.3 days in the pre-KAS cohort (p = 0.98). The median KDPI for PLD recipients was 31% with KAS versus 23% before KAS (p = 0.02). Despite a sharp decrease in the MWT for highly prioritized candidates with calculated panel reactive antibodies of 98-100% (from >7000 to 1164 days), PLDs still had much shorter waiting times (MWT 102.6 days). The new system continues to provide quick access to high-quality organs for PLDs.

Quantifying accessibility and use of improved sanitation: towards a comprehensive indicator of the need for sanitation interventions

To prevent diseases associated with inadequate sanitation and poor hygiene, people needing latrines and behavioural interventions must be identified. We compared two indicators that could be used to identify those people. Indicator 1 of household latrine coverage was a simple Yes/No response to the question “Does your household have a latrine?” Indicator 2 was more comprehensive, combining questions about defecation behaviour with observations of latrine conditions. Using a standardized procedure and questionnaire, trained research assistants collected data from 6,599 residents of 16 rural villages in Indonesia. Indicator 1 identified 30.3% as not having a household latrine, while Indicator 2 identified 56.0% as using unimproved sanitation. Indicator 2 thus identified an additional 1,710 people who were missed by Indicator 1. Those 1,710 people were of lower socioeconomic status (p < 0.001), and a smaller percentage practiced appropriate hand-washing (p < 0.02). These results show how a good indicator of need for sanitation and hygiene interventions can combine evidences of both access and use, from self-reports and objective observation. Such an indicator can inform decisions about sanitation-related interventions and about scaling deworming programmes up or down. Further, a comprehensive and locally relevant indicator allows improved targeting to those most in need of a hygiene-behaviour intervention.

Birth and Empowerment: A Qualitative Study of the Childbirth Experience of Filipino Migrant Women in Brisbane, Australia

This project aims to understand and explore the notion of empowerment in relation to the childbirth experiences of Filipino women in Brisbane, Australia. Objectives include assessing the responsiveness of the health system to Filipino migrant women; exploring different cultural perspectives on childbirth; and assessing the understanding of the health rights of Filipinas in relation to child and maternal health services. The overwhelming majority of the women in the sample were found to have experienced problems with their childbirth. Most reported that these were due to discrimination, language difficulties, a lack of emotional and social support, marked cultural differences with respect to pregnancy, childbirth and the post-partal care of mother and child. They also reported a lack of knowledge and information about Australian maternal and child health care services. Despite successful clinical outcomes it is suggested that the notion of empowerment could provide insight into ways of improving the birth experience in order to ameliorate many of the problems typical of this group.

Human Rights Issues and Health Practices

On the occasion of the 50th anniversary of the Universal Declaration of Human Rights and in the context of current adverse economic circumstance in the Asia-Pacific region, it is apparent that we still have a long way to go before we can claim adequate promotion and protection of fundamental freedoms, human rights and health rights. New approaches to public health and a social, or population definition of health requires an active engagement with human rights and a recognition of the ethical domain. Such an engagement is assisted by the articulation of some of the fundamental principles underlying various Conventions, Charters and Declarations and the contribution of liberal moral and political theory to such documents. Such liberal traditions have been challenged for their ethnocentrism and western cultural bias. However it is argued that they form a basis for important universal standards which can assist public health practitioners as they navigate through the turbulent waters of human rights issues and health practices.

The OPTN Deceased Donor Potential Study: Implications for Policy and Practice

The Organ Procurement and Transplantation Network (OPTN) Deceased Donor Potential Study, funded by the Health Resources and Services Administration, characterized the current pool of potential deceased donors and estimated changes through 2020. The goal was to inform policy development and suggest practice changes designed to increase the number of donors and organ transplants. Donor estimates used filtering methodologies applied to datasets from the OPTN, the National Center for Health Statistics, and the Agency for Healthcare Research and Quality and used these estimates with the number of actual donors to estimate the potential donor pool through 2020. Projected growth of the donor pool was 0.5% per year through 2020. Potential donor estimates suggested unrealized donor potential across all demographic groups, with the most significant unrealized potential (70%) in the 50-75-year-old age group and potential Donation after Circulatory Death (DCD) donors. Actual transplants that may be realized from potential donors in these categories are constrained by confounding medical comorbidities not identified in administrative databases and by limiting utilization practices for organs from DCD donors. Policy, regulatory, and practice changes encouraging organ procurement and transplantation of a broader population of potential donors may be required to increase transplant numbers in the United States.

Changes in Deceased Donor Kidney Transplantation One Year After KAS Implementation

After over a decade of discussion, analysis, and consensus-building, a new kidney allocation system (KAS) was implemented on December 4, 2014. Key goals included improving longevity matching between donor kidneys and recipients and broadening access for historically disadvantaged subpopulations, in particular highly sensitized patients and those with an extended duration on dialysis but delayed referral for transplantation. To evaluate the early impact of KAS, we compared Organ Procurement and Transplantation Network data 1 year before versus after implementation. The distribution of transplants across many recipient characteristics has changed markedly and suggests that in many ways the new policy is achieving its goals. Transplants in which the donor and recipient age differed by more than 30 years declined by 23%. Initial, sharp increases in transplants were observed for Calculated Panel-Reactive Antibody 99-100% recipients and recipients with at least 10 years on dialysis, with a subsequent tapering of transplants to these groups suggesting bolus effects. Although KAS has arguably increased fairness in allocation, the potential costs of broadening access must be considered. Kidneys are more often being shipped over long distances, leading to increased cold ischemic times. Delayed graft function rates have increased, but 6-month graft survival rates have not changed significantly.

What are the risk factors for HIV in men who have sex with men in Ho Chi Minh City, Vietnam?- A cross-sectional study

BACKGROUND

The number of people living with HIV (PLWH) in Vietnam was estimated to rise from 156,802 in 2009 to 256,000 in 2014. Although the number of new HIV reported cases has decreased by roughly 14,000 cases per year from 2010 to 2013 a concerning increase in HIV prevalence has been identified among men who have sex with men (MSM) from 1.7 % in 2005 to 2.4 % in 2013. There are signs of increased HIV (+) prevalence among MSM in a number of cities/provinces, especially in the two largest cities, Ho Chi Minh City (HCMC) and Hanoi. HCMC is the country's major "hot spot" for HIV/AIDS, with over a third of the total national AIDS patients. This paper is based on a secondary analysis of Integrated Biological and Behavioural Surveillance (IBBS) data collected in Vietnam in 2009 to examine the research question "Do behavioural risk factors contribute to HIV infection among the MSM population in HCMC?".

METHODS

A cross-sectional design was employed to sample males aged over 15 from communities in HCMC, who reported having any types of sex with another man at least once during the last 12 months. Participants (399) were recruited using the respondent driven sampling (RDS) method and provided both biological data (specimens) and behavioural data collected through a questionnaire survey.

RESULTS

The study found high HIV prevalence (14.8 %) among the MSM sample from HCMC. Multivariate analysis found age and level of formal education completed, to be significantly associated with HIV infection. MSM aged over 25 were more likely to be HIV (+) than the younger group (OR = 7.82, 95 %CI = 3.37-18.16, p < 0.001); as were participants who had low educational (OR = 2.74, p < 0.05) and medium educational levels (OR = 2.68, p < 0.05). In addition, those participants who had anal sex with male partners (OR = 2.7, p < 0.05) and whose sexual partners injected drugs (OR = 2.24, p < 0.05) and who felt at risk of HIV infection (OR = 2.42, p < 0.01) had a higher risk of HIV infection.

CONCLUSIONS

The high proportion of HIV (+) MSM in our sample from HCMC indicates that we need a better understanding of MSM behaviour patterns, risk practices and social networks as well as improved HIV prevention and control measures. More targeted and relevant HIV prevention programs for older and less educated MSM are urgently needed to address the key risk factors we have identified. MSM engaging in drug-related risk behaviours require multi-strategy HIV interventions relating to both sex and drug behaviour among MSM and their partners who engage in drug use. Further work is needed to identify locations and strategies where these high-risk individuals can be accessed as well as to reduce barriers related to social discrimination and stigma. Targeting high risk individuals and groups should supplement existing efforts aimed at the MSM population in HCMC.

Trends and Patterns in Reporting of Patient Safety Situations in Transplantation

Analysis and dissemination of transplant patient safety data are essential to understanding key issues facing the transplant community and fostering a "culture of safety." The Organ Procurement and Transplantation Network's (OPTN) Operations and Safety Committee de-identified safety situations reported through several mechanisms, including the OPTN's online patient safety portal, through which the number of reported cases has risen sharply. From 2012 to 2013, 438 events were received through either the online portal or other reporting pathways, and about half were self-reports. Communication breakdowns (22.8%) and testing issues (16.0%) were the most common types. Events included preventable errors that led to organ discard as well as near misses. Among events reported by Organ Procurement Organization (OPOs), half came from just 10 of the 58 institutions, while half of events reported by transplant centers came from just 21 of 250 institutions. Thirteen (23%) OPOs and 155 (62%) transplant centers reported no events, suggesting substantial underreporting of safety-related errors to the national database. This is the first comprehensive, published report of the OPTN's safety efforts. Our goals are to raise awareness of safety data recently reported to the OPTN, encourage additional reporting, and spur systems improvements to mitigate future risk.

OPTN/SRTR 2013 Annual Data Report: kidney

A new kidney allocation system, expected to be implemented in late 2014, will characterize donors on a percent scale (0%-100%) using the kidney donor profile index (KDPI). The 20% of deceased donor kidneys with the greatest expected posttransplant longevity will be allocated first to the 20% of candidates with the best expected posttransplant survival; kidneys that are not accepted will then be offered to remaining 80% of candidates. Waiting time will start at the time of maintenance dialysis initiation (even if before listing) or at the time of listing with an estimated glomerular filtration rate of 20 mL/min/1.73 m(2) or less. Under the current system, the number of candidates on the waiting list continues to increase, as each year more candidates are added than are removed. Median waiting times for adults increased from 3 years in 2003 to more than 4.5 years in 2009. Donation rates have not increased. Short-term outcomes continue to improve; death-censored graft survival at 90 days posttransplant was 97% or higher for deceased donor transplants and over 99% for living donor transplants. In 2013, 883 pediatric candidates were added to the waiting list; 65.8% of pediatric candidates on the list in 2013 underwent deceased donor transplant. Five-year graft survival was highest for living donor recipients aged younger than 11 years (89%) and lowest for deceased donor recipients aged 11 to 17 years (68%).

OPTN/SRTR 2012 Annual Data Report: kidney

For most end-stage renal disease patients, successful kidney transplant provides substantially longer survival and better quality of life than dialysis, and preemptive transplant is associated with better outcomes than transplants occurring after dialysis initiation. However, kidney transplant numbers in the us have not changed for a decade. Since 2004, the total number of candidates on the waiting list has increased annually. Median time to transplant for wait-listed adult patients increased from 2.7 years in 1998 to 4.2 years in 2008. The discard rate of deceased donor kidneys has also increased, and the annual number of living donor transplants has decreased. The number of pediatric transplants peaked at 899 in 2005, and has remained steady at approximately 750 over the past 3 years; 40.9% of pediatric candidates undergo transplant within 1 year of wait-listing. Graft survival continues to improve for both adult and pediatric recipients. Kidney transplant is one of the most cost-effective surgical interventions; however, average reimbursement for recipients with primary Medicare coverage from transplant through 1 year posttransplant was comparable to the 1-year cost of care for a dialysis patient. Rates of rehospitalization are high in the first year posttransplant; annual costs after the first year are lower.

Does a socio-ecological school model promote resilience in primary schools?

BACKGROUND

This research investigates the extent to which the holistic, multistrategy "health-promoting school" (HPS) model using a resilience intervention can lead to improved resilience among students.

METHODS

A quasi-experimental design using a study cohort selected from 20 primary schools in Queensland, Australia was employed. Ten intervention schools using HPS protocols, with training support, were compared with 10 control schools in student resilience scores and protective factors. Baseline data explored the interactive effect of protective factors on overall resilience scores. Postintervention analysis compared changes in protective factors and resilience, after implementing the HPS project.

RESULTS

Baseline data analysis indicated no significant differences in the mean scores of protective factors and resilience scores between intervention and control groups (except for school connection). After 18 months of implementation, a resurvey showed that the intervention group had significantly higher scores than the control group on students' family connection, community connection, peer support, and their overall resilience.

CONCLUSIONS

Results showed that students in the HPS group had significantly higher scores on resilience than did students in the control group. A comprehensive, whole-school approach to building resilience that integrates students, staff, and community can strengthen important protective factors and build student resilience.

OPTN/SRTR 2011 Annual Data Report: kidney

A shortage of kidneys for transplant remains a major problem for patients with end-stage renal disease. The number of candidates on the waiting list continues to increase each year, while organ donation numbers remain flat. Thus, transplant rates for adult wait-listed candidates continue to decrease. However, pretransplant mortality rates also show a decreasing trend. Many kidneys recovered for transplant are discarded, and discard rates are increasing. Living donation rates have been essentially unchanged for the past decade, despite introduction of desensitization, non-directed donations, and kidney paired donation programs. For both living and deceased donor recipients, early posttransplant results have shown ongoing improvement, driven by decreases in rates of graft failure and return to dialysis. Immunosuppressive drug use has changed little, except for the Food and Drug Administration approval of belatacept in 2011, the first approval of a maintenance immunosuppressive drug in more than a decade. Pediatric kidney transplant candidates receive priority under the Share 35 policy. The number of pediatric transplants peaked in 2005, and decreased to a low of 760 in 2011. Graft survival and short-term renal function continue to improve for pediatric recipients. Postransplant lymphoproliferative disorder is an important concern, occurring in about one-third of pediatric recipients.

Center-level patterns of indicated willingness to and actual acceptance of marginal kidneys

UNet(SM) , the UNOS data collection and electronic organ allocation system, allows centers to specify organ offer acceptance criteria for patients on their kidney waiting list. We hypothesized that the system might not be fully utilized and that the criteria specified by most transplant centers would be much broader than the characteristics of organs actually transplanted by those centers. We analyzed the distribution of criteria values among waitlist patients (N = 304 385) between January 2000 and February 2009, mean criteria values among listed candidates on February 19, 2009 and differences between a center's specified criteria and the organs it accepted for transplant between July 2005 and April 2009. We found wide variation in use of criteria variables, with some variables mostly or entirely unused. Most centers specified very broad criteria, with little within-center variation by patient. An offer of a kidney with parameters more extreme than the maximum actually transplanted at that center was designated a 'surplus offer' and indicated a potentially avoidable delay in distribution. We found 7373 surplus offers (7.1% of all offers), concentrated among a small number of centers. The organ acceptance criteria system is currently underutilized, leading to possibly avoidable inefficiencies in organ distribution.

The Australian preventive health agenda: what will this mean for workforce development?

The formation of the National Health and Hospitals Reform Commission (NHHRC) and the National Preventative Task Force in 2008, demonstrate a renewed Australian Government commitment to health reform. The re-focus on prevention, bringing it to the centre of health care has significant implications for health service delivery in the primary health care setting, supportive organisational structures and continuing professional development for the existing clinical and public health workforce. It is an opportune time, therefore, to consider new approaches to workforce development aligned to health policy reform. Regardless of the actual recommendations from the NHHRC in June 2009, there will be an emphasis on performance improvements which are accountable and aligned to new preventive health policy, organisational priorites and anticipated improved health outcomes.

To achieve this objective there will be a need for the existing population health workforce, primary health care and non-government sectors to increase their knowledge and understanding of prevention, promotion and protection theory and practice within new organisational frameworks and linked to the community. This shift needs to be part of a national health services research agenda, infrastructure and funding which is supportive of quality continuing professional development.

This paper discusses policy and practice issues related to workforce development as part of an integrated response to the preventive agenda.

Individual and contextual factors associated with follow-up use of diabetes self-management education programmes: a multisite prospective analysis

AIMS

Although a considerable body of research supports the efficacy of diabetes self-management education (DSME), these programmes are often challenged by high attrition rates. Little is known about factors influencing follow-up use of DSME services, thus the aim of this study was to identify these factors.

METHODS

In this multisite prospective analysis, adults with Type 2 diabetes (n = 268) who attended one of two diabetes management centres (DMCs) were followed over a 1-year period from their initial visit. The influence of individual and contextual factors on the number of contacts with DMC providers was examined. Data were analysed within the context of the Health Behavioral Model of Health Services Utilization.

RESULTS

In a multivariable negative binomial regression model, the number of contacts over 1 year was greater for those who were female, non-smokers, unemployed, self-referred to the DMC, lived closer to the DMC, had a lower body mass index, or had a longer known duration of diabetes. Follow-up use of services differed significantly between the two sites. Provider contacts were greater at the centre that offered flexible hours of services and a variety of optional educational modules.

CONCLUSIONS

Healthcare professionals need to encourage ongoing use of DSME, particularly for individuals prone to lower follow-up use of these services. Providing services that are accessible, convenient, and can easily fit into patients' schedules may increase follow-up use. Further exploration into how operations and delivery of these services influence utilization patterns is strongly recommended.

Effect of peer support on prevention of postnatal depression among high risk women: multisite randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of telephone based peer support in the prevention of postnatal depression.

DESIGN

Multisite randomised controlled trial.

SETTING

Seven health regions across Ontario, Canada.

PARTICIPANTS

701 women in the first two weeks postpartum identified as high risk for postnatal depression with the Edinburgh postnatal depression scale and randomised with an internet based randomisation service.

INTERVENTION

Proactive individualised telephone based peer (mother to mother) support, initiated within 48-72 hours of randomisation, provided by a volunteer recruited from the community who had previously experienced and recovered from self reported postnatal depression and attended a four hour training session.

MAIN OUTCOME MEASURES

Edinburgh postnatal depression scale, structured clinical interview-depression, state-trait anxiety inventory, UCLA loneliness scale, and use of health services.

RESULTS

After web based screening of 21 470 women, 701 (72%) eligible mothers were recruited. A blinded research nurse followed up more than 85% by telephone, including 613 at 12 weeks and 600 at 24 weeks postpartum. At 12 weeks, 14% (40/297) of women in the intervention group and 25% (78/315) in the control group had an Edinburgh postnatal depression scale score >12 (chi(2)=12.5, P<0.001; number need to treat 8.8, 95% confidence interval 5.9 to 19.6; relative risk reduction 0.46, 95% confidence interval 0.24 to 0.62). There was a positive trend in favour of the intervention group for maternal anxiety but not loneliness or use of health services. For ethical reasons, participants identified with clinical depression at 12 weeks were referred for treatment, resulting in no differences between groups at 24 weeks. Of the 221 women in the intervention group who received and evaluated their experience of peer support, over 80% were satisfied and would recommend this support to a friend.

CONCLUSION

Telephone based peer support can be effective in preventing postnatal depression among women at high risk.

TRIAL REGISTRATION

ISRCTN 68337727.

Healthcare worker's perceptions of barriers to care by immigrant women with postpartum depression: an exploratory qualitative study

OBJECTIVE

We interviewed healthcare workers working in Toronto, Canada, regarding their experience of providing care to recent immigrant women suffering from postpartum depression. The objective was two-fold: 1) to identify potential barriers to care that recent immigrant women may encounter as perceived by healthcare workers; and 2) to identify challenges healthcare workers felt that they faced as providers of care to this population.

METHODS

Qualitative semi-structured interviews were conducted with 16 key informants from various disciplines employed by healthcare agencies providing care to postpartum immigrant women in Toronto. Constant comparative analysis was used to analyze the data.

RESULTS

Two main categories of barriers to care for recent immigrant women were identified: 'practical barriers' and 'culturally determined barriers'. Practical barriers included knowing where and how to access services, and language difficulties. Cultural barriers included fear of stigma and lack of validation of depressive symptoms by family and society. The challenges experienced by healthcare providers working with this population were organized into two other categories: 'professional limitations', and 'social/cultural barriers'. 'Professional limitations' included fear of incompetence, language barriers, and inadequate assessment tools. 'Social/cultural barriers' included the experience of cultural uncertainty.

CONCLUSIONS

The results suggest that not only are there important barriers to accessing postpartum care for recent immigrant women, but it can also be challenging for healthcare workers to deliver such needed care. Understanding some of these barriers and challenges from the perspective of healthcare providers is an important step to remedying gaps and obstacles in the service system.

Women's mental health: a silent cause of mortality and morbidity

It is estimated that 450 million individuals worldwide are affected by mental, neurological or behavioral problems at any time, and that 873,000 die annually by suicide. Key international authorities and a literature review suggest that women are disproportionately affected by depression, anxiety and eating disorders, which usually go unrecognized and untreated, and that the mental health of women can be understood only if their biological, social, cultural, economic and personal context is considered. International efforts should increase to prevent, recognize and treat mental disorders in girls and women. An International Women's Mental Health Consensus Statement is herein provided, for endorsement by interested organizations wishing to begin this task.

The effect of postpartum depression on child cognitive development and behavior: a review and critical analysis of the literature

The incidence of postpartum depression (PPD) in Western societies is approximately 10-15% and its cause multi-faceted. Because mothers largely constitute infants' social environment and mediate their experience of the external world, it is imperative to investigate the effects of PPD on child growth and development. PsycInfo, Medline, Embase, CINAHL, ProQuest, and Health Star databases were searched with key terms for English language abstracts from 1990 onwards, and key contents were searched. There are small effects of PPD on cognitive development such as language and IQ, seen particularly among boys. Behavioral effects are variably supported, but may persist up to 5 years postpartum and beyond. However, chronic or recurrent maternal depression, rather than postpartum depression per se is likely related to later effects on the child. These adverse effects of PPD based on sex of infant are discussed.

The confounding effects of age, gender, serum creatinine, and electrolyte concentrations on plasma B-type natriuretic peptide concentrations in critically ill patients

OBJECTIVE

To investigate the confounding effects of age, gender, serum creatinine, and electrolyte concentrations on plasma B-type natriuretic peptide (BNP) concentrations in critically ill patients.

DESIGN

A prospective cross-sectional study.

SETTING

A 20-bed general intensive care unit of a tertiary referral hospital.

PATIENTS

Patients were 121 patients admitted to the intensive care unit over a period of 9 wks.

INTERVENTIONS

Intravenous blood was collected for BNP measurements, and cardiac investigations including echocardiography were carried out for every patient on admission.

MEASUREMENTS AND MAIN RESULTS

The mean BNP concentration was 201 +/- 317 pg/mL (n = 121). Thirty-five patients (28.9%), identified to have cardiac abnormalities, exhibited higher BNP concentrations than those without cardiac abnormalities (518 +/- 394 vs. 60 +/- 98 pg/mL, p <.001). The females exhibited higher concentrations of BNP than males in the noncardiac abnormality group (96 +/- 132 pg/mL, n = 39 vs. 31 +/- 38 pg/mL, n = 47, p =.016). BNP correlated significantly with age (r2 =.19) and creatinine (r2 =.084). The latter correlation became insignificant when patients with cardiac abnormality were excluded. No correlation was found between serum Na+ and K+ concentrations with BNP. Multivariate analyses demonstrated that the presence of cardiac abnormalities accounted for nearly 50% of the BNP variation. Addition of age and gender improved R2 to 60%. The contribution of creatinine was found to be insignificant. There was no association between BNP concentrations and serum Na+ and K+ concentrations. Logistic analysis confirmed that BNP is the strongest predictor for cardiac abnormalities in the critically ill patients.

CONCLUSION

The current study demonstrated that plasma BNP concentrations increased with age and were higher in females than in males. Although the presence of cardiac disease was the most important determinant for BNP variations, age and gender also contributed significantly. The results suggest that age and gender need to be taken into account in the interpretation of BNP concentrations in critically ill patients.

Physician health, stress and gender at a university hospital

OBJECTIVE

To determine personal and work related factors contributing to physician health and stress in men and women physicians in a university hospital.

METHOD

Mail survey of 161 hospital-based Canadian academic physicians (51 women, 110 men).

RESULTS

Women compared to men, physicians were younger (M = 43 years, S.D. = 7.4 vs. M = 48 years, S.D. = 8.64; P = .001) and fewer had spouses (76% vs. 90%; P = .01) and children (76% vs. 91%; P = .02). A five-item scale measured somatic symptoms, the dependent variable. Among physicians of both gender, the somatic symptoms scale was significantly correlated with satisfaction with amount of time spent working and scales of mental health (five items), work satisfaction (five items), workload (five items), healthy lifestyle (five items), coping abilities (three items) and support-in-stress (two items). On stepwise regression analysis, for women physicians, 70% of the variance in somatic symptoms was explained by support from colleagues when stressed, and workload. For men, 42% of the variance was explained by healthy lifestyle, mental health, support from colleagues when stressed, and workload. Regardless of gender, the majority of physicians reported an excessive workload but the sources of support when stressed varied by gender.

CONCLUSION

Different strategies are needed for women and men physicians to reduce their stress levels.

Increased B-type natriuretic peptide (BNP) level is a strong predictor for cardiac dysfunction in intensive care unit patients

Patients admitted to an Intensive Care Unit (ICU) frequently have underlying cardiac dysfunction. Early interventions are sometimes difficult to initiate because of diagnostic uncertainty as to whether cardiac failure is present As B-type natriuretic peptide (BNP) has been shown to be increased in cardiac dysfunction, we sought to demonstrate whether BNP can be used as a screening tool for cardiac dysfunction in patients admitted to ICU. All patients admitted to a combined medical and surgical ICU over a four-week period were included in the study. BNP was measured on the point of admission using a hand-held meter. Clinicians were blinded from the measurement when diagnoses were made as to whether or not the patients had clinically significant cardiac dysfunction. Patients with cardiac dysfunction had a significantly higher level of BNP when compared to the non-cardiac dysfunction group: 516 +/- 385 pg/ml (n = 26) v 67 +/- 89 pg/ml (n = 58) (P < 0.0001) A BNP cut-off value at 144 pg/ml exhibited a 92% sensitivity, 86% specificity and 96% negative predictive value. The sensitivity improved to 96% when the analysis was confined to patients > or = 55 years. At this cut-off value, BNP is a strong predictor of cardiac dysfunction. BNP measurement offers a rapid and affordable way to screen for cardiac dysfunction in patients admitted to ICU. An increased BNP level warrants further cardiac investigations so as to implement early interventions for cardiac decompensation in ICU patients.

"What doesn't kill you makes you stronger": an ovarian cancer survivor survey

OBJECTIVES

This survey was designed to learn more about the physical health and quality of life of ovarian cancer survivors without known active disease and not on treatment.

METHODS

Women with ovarian cancer without evidence of active disease, and not on treatment for at least 2 years, were recruited in Canada and the United States from university cancer clinics, community ovarian support groups, and a cancer survivor network newsletter and asked to complete an anonymous mail-back survey on their physical, psychological, social, and spiritual well-being.

RESULTS

Two-hundred (67.5%) women responded. Their mean age was 55.3 years, 72.5% had children, and they had been diagnosed with ovarian cancer a mean of 7.2 years previously. Eighty-nine percent regarded their health as good or excellent, but 53.5% had current pain or discomfort. They reported better mental health and equivalent energy levels to the general population. Although 57% reported that their sex lives had been negatively affected by cancer and its treatment, their overall sense of loss relating to sexual functioning was moderate to low. However, women under age 55 years reported a greater sense of loss about sexual function and fertility (P = 0.001). Most women reported that their ovarian cancer experience had changed their views on life and relationships in an overwhelmingly positive way.

CONCLUSION

Most ovarian cancer survivors, despite some symptoms, enjoyed good physical, psychological, social, and spiritual health. Specific concerns emerged about sexuality which should be addressed in patient education. Having survived a life-threatening illness, ovarian cancer survivors appear to have put other life difficulties into perspective, altered their priorities, and felt enriched by the experience. In general, these women showed impressive and inspiring resilience and reported good physical health and energy, excellent psychological health, and feelings of greater pleasure in life and personal relationships.

The views of ovarian cancer survivors on its cause, prevention, and recurrence

METHODS

Women who had survived ovarian cancer without further treatment, active disease, or recurrence for at least 2 years were surveyed by mail.

RESULTS

Two hundred (67.8%) ovarian cancer survivors, who had been recurrence free for a mean of 7.2 +/- 4.9 years, responded. The cause of ovarian cancer was attributed to stress (63.5%), diet (39.0%), genes (36.5%), environment (32.5%), hormones (30.0%), sex life (11.0%), and smoking (9.5%). They attributed their lack of cancer recurrence to positive attitude (82.5%), close medical follow-up (82.0%), healthy lifestyle (69.0%), prayer (68.0%), stress reduction (66.5%), diet (63.0%), and exercise (58.5%). Overall, 45% of women thought their recurrence risk was below average, 28.5% average, 23% above average, and 3.5% reported that they did not know their particular risk. Although 35.5% of women reported that they hardly ever thought of cancer recurrence, 28% thought of it at least monthly, 24.5% at least weekly, and 12% at least daily. Almost half (43.5%) of the women had bad dreams related to their cancer experience, and 25% of these women reported the dreams had a negative effect on their sense of well-being. Over half (62.5%) reported high to extreme anxiety at the time of cancer check-ups, but 47% were not afraid of what their futures held for them. However, 12% were very afraid of dying of ovarian cancer, and 5% were "constantly afraid of dying." Most women reported healthy behaviors with respect to not smoking (95.5%), balanced diet (92.0%), and regular exercise (65.0%). Of note was that 82% took vitamins or other supplements.

CONCLUSION

Healthcare providers should be aware that the personal beliefs held by ovarian cancer patients and survivors about cancer cause and recurrence prevention may be at variance with scientific evidence. This may assist in framing the ongoing management of patients in personally meaningful ways, which may increase adherence to a healthy lifestyle, engender a sense of control, and improve quality of life.

The disconnect: infertility patients' information and the role they wish to play in decision making

OBJECTIVE

To determine the preferred role in medical decision making of women undergoing fertility treatments and to establish whether their knowledge of treatments is adequate to inform their choices.

METHODS

Self-report survey of 404 women undergoing fertility treatments in 2 university hospitals and a private fertility clinic in Canada.

RESULTS

The women had been in fertility treatment for 2.3 +/- 2.6 years; 67.8% reported taking fertility drugs. Most (61.7%) women wanted to share knowledge equally with their doctors about possible fertility treatments. However, about half wanted to decide alone or mostly by themselves about the acceptability of treatment risks and benefits (56%), what treatments should be selected (49.8%), and when to conclude treatments (54.3%). In addition, 55.1% of the women did not know their personal eventual chances of pregnancy with fertility treatment or thought it was 50% or greater. Over half of the women (57.2%) who had taken fertility drugs were unaware of a possible link between fertility drugs and increased ovarian cancer risk. The majority of women (61.8%) who knew of this possible association reported that they learned about it from the print media. Women who knew of the association had a poor understanding of the strength of the evidence or the ability to detect or treat ovarian cancer successfully, and 88.3% thought they could reduce cancer risk by following their doctors' advice.

CONCLUSIONS

Despite these women's wishes to actively participate in fertility treatment decisions, they lacked the necessary information to do so meaningfully. Public health policymakers, professional and advocacy organizations, physicians, other healthcare providers, and women themselves must find ways to improve the general public's and patients' understanding about fertility treatment outcomes and risks.

Perceptions of primary healthcare services among people with physical disabilities - part 1: access issues

BACKGROUND

Access to primary healthcare among people with physical disabilities has been a neglected research area in Canada. The authors sought to examine the extent of access to and satisfaction with primary healthcare services for people with physical disabilities living in Canada's largest metropolitan area -- the Toronto region.

METHODS

An anonymous self-report questionnaire regarding access to and perceived quality of primary healthcare was mailed to a convenience sample of 1026 members of several disability organizations as well as persons discharged from a rehabilitation hospital within the past 2 years. For the 201 returned surveys (response rate = 20%), the authors evaluated the perceived extent of access to primary healthcare services as well as the level of satisfaction with the quality of these services.

RESULTS

Among the respondents to the questionnaire, 17.4% reported having difficulty obtaining a family doctor's services and 8.0% reported having been refused medical treatment by a family doctor because of their disability. Respondents also reported difficulty in physically accessing their family doctor's office (32.3%), equipment (38.3%), and washroom (22.9%). Although 82.1% of respondents claimed they were very or somewhat satisfied with their family doctor's services, 19.4% felt they were receiving inadequate primary healthcare and 21.9% felt that their disability prevented them from receiving appropriate primary healthcare.

DISCUSSION

Although people who experienced more difficulties may have been more likely to respond to this survey, a significant proportion of people with physical disabilities feel they are experiencing difficulty accessing adequate and appropriate primary healthcare services. Possible solutions to some of the identified access barriers and areas where further research may be required are described.

Perceptions of primary healthcare services among persons with physical disabilities - part 2: quality issues

BACKGROUND

The ability of persons with disabilities to access quality primary care in Canada is not well documented. This article reports on the perceived quality of primary care received by persons with disabilities by looking at utilization of elements of the health maintenance examination, referrals, health promotion, healthcare provider role clarification, and satisfaction.

METHODS

A sample of convenience was undertaken whereby an anonymous self-report questionnaire, which included the Short Form-36 Health Survey, was mailed to members of several Canadian disability organizations and persons discharged within the last 2 years from a rehabilitation hospital. The Statistical Package for the Social Sciences was used to analyze the data.

RESULTS

A total of 201 individuals (20% response rate) completed and returned the surveys, 61.2% of whom were women. Some elements of the health maintenance examination, including Pap tests, mammogram referral, and measurement of blood pressure (BP), were not markedly different from population census data. Inquiry around health promotion was low, as 61.7% of our sample did not receive a functional assessment, 58.2% were not asked about emotions, and only 10% were asked about physical or sexual violence. Diet, exercise, smoking, pain, sleep, alcohol, sex, sexually transmitted diseases (STDs), and reproductive choices were discussed in varying degrees.

INTERPRETATION

Among respondents in our survey, disabled women were able to access important screening tests. Health promotion services, however, were often not offered. The particular healthcare needs of disabled women and men -- eg, having a condition that may be progressive, being at increased risk of secondary disability and the added effects of aging -- may be addressed more effectively by including health promotion. It is proposed that functional assessment, emotional inquiry, and role clarification could improve the delivery of health promotion and the perceived quality of care received.

Decentralization and human resource management in the health sector: a case study (1996-1998) from Nampula province, Mozambique

Despite political, cultural and geographical diversity, health care reforms implemented in many developing countries share a number of common features regarding management and structural issues. Decentralization of decision-making from the central authority to local and provincial levels is generally regarded in the literature to be an important way of achieving a more equitable distribution of health care and better management practices, aligned with local priorities and needs. However, in the absence of clear guidelines, continuous monitoring and an adequate supply of financial and human resources, decentralization processes are more likely to have a low impact on the process of health care reform and can, to a certain extent, provoke inequalities between regions in the same country. This qualitative study in Nampula province, Mozambique, was conducted to assess the impact of decentralization, through an analysis of the viewpoints of provincial health managers regarding their perceptions of the process, particularly with regard to the management of basic and elementary nurses. Secondary data from Nampula provincial reports and documents from the Mozambican Health Ministry were also reviewed and comparisons made with the experiences of other developing countries.

Who develops severe or fatal adverse drug reactions to selective serotonin reuptake inhibitors?

OBJECTIVE

To ascertain the risk factors associated with the development of severe and fatal adverse drug reactions (ADRs) or intentional overdoses by patients on selective serotonin reuptake inhibitors (SSRIs).

METHODS

We undertook a data analysis of Health Canada's database of Adverse Drug Reactions to SSRIs from 1986 to 1996, as well as a literature review.

RESULTS

Among the complete ADR reports in the SSRI database, there were no sex differences in occurrences of all ADRs (n = 1011), severe ADRs (n = 295), drug-drug interactions (n = 312), deaths (n = 87), or intentional overdoses (n = 79), when sex differences in prescription practices were considered. There were no differences in ADR rates among different SSRIs. The most common cause of death among patients taking SSRIs was intentional overdose (n = 65, 74.7%). This was reported in 47 (72.3%) women and 18 (27.7%) men. The most common drugs taken with SSRIs in patients who died of intentional overdoses were benzodiazepines, tricyclic antidepressants (TCAs), narcotics, alcohol, and diphenhydramine. Patients who had severe or fatal ADRs were more likely to be taking an SSRI with 2 or more other drugs, including alcohol. Drug combinations that included another CYP-450 drug were especially problematic. A total of 129 cardiovascular ADRs were reported, most of which were severe. These included rhythm disturbances, blood pressure perturbations, and chest pain or angina. Cardiovascular ADRs most often occurred with concomitant drug use of benzodiazepines, TCAs, histamine H2 antagonists, lithium, and calcium channel blockers. There were 3 deaths from malignant neuroleptic syndrome unassociated with intentional overdose.

CONCLUSIONS

SSRIs are relatively safe when their widespread use is compared with the prevalence of ADRs. SSRIs may, however, be associated with ADRs, and even death, following intentional overdose or when taken with 2 or more other drugs or alcohol (particularly another drug metabolized by CYP-450). Physicians prescribing SSRIs need to consider drug-drug interactions and carefully monitor patients with severe affective disorders, comorbid medical conditions (especially cardiovascular disease), alcohol abuse, or a history of overdosing.