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Appropriate training and retention of community doctors in rural areas: a case study from Mali
No full textBackground
While attraction of doctors to rural settings is increasing in Mali, there is concern for their retention. An orientation course for young practicing rural doctors was set up in 2003 by a professional association and a NGO. The underlying assumption was that rurally relevant training would strengthen doctors' competences and self-confidence, improve job satisfaction, and consequently contribute to retention.
Methods
Programme evaluation distinguished trainees' opinions, competences and behaviour. Data were collected through participant observation, group discussions, satisfaction questionnaires, a monitoring tool of learning progress, and follow up visits. Retention was assessed for all 65 trainees between 2003 and 2007.
Results and discussion
The programme consisted of four classroom modules – clinical skills, community health, practice management and communication skills – and a practicum supervised by an experienced rural doctor. Out of the 65 trained doctors between 2003 and 2007, 55 were still engaged in rural practice end of 2007, suggesting high retention for the Malian context. Participants viewed the training as crucial to face technical and social problems related to rural practice. Discussing professional experience with senior rural doctors contributed to socialisation to novel professional roles. Mechanisms underlying training effects on retention include increased self confidence, self esteem as rural doctor, and sense of belonging to a professional group sharing a common professional identity. Retention can however not be attributed solely to the training intervention, as rural doctors benefit from other incentives and support mechanisms (follow up visits, continuing training, mentoring...) affecting job satisfaction.
Conclusion
Training increasing self confidence and self esteem of rural practitioners may contribute to retention of skilled professionals in rural areas. While reorientations of curricula in training institutions are necessary, other types of professional support are needed. This experience suggests that professional associations dedicated to strengthening quality of care can contribute significantly to rural practitioners' morale
High risk of severe anaemia after chlorproguanil-dapsone+artesunate antimalarial treatment in patients with G6PD (A-) deficiency
No full textBackground
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common inherited human enzyme defect. This deficiency provides some protection from clinical malaria, but it can also cause haemolysis after administration of drugs with oxidant properties.
Methods
The safety of chlorproguanil-dapsone+artesunate (CD+A) and amodiaquine+sulphadoxine-pyrimethamine (AQ+SP) for the treatment of uncomplicated P. falciparum malaria was evaluated according to G6PD deficiency in a secondary analysis of an open-label, randomized clinical trial [1]. 702 children, treated with CD+A or AQ+SP and followed for 28 days after treatment were genotyped for G6PD A- deficiency.
Findings
In the first 4 days following CD+A treatment, mean haematocrit declined on average 1.94% (95% CI 1.54 to 2.33) and 1.05% per day (95% CI 0.95 to 1.15) respectively in patients with G6PD deficiency and normal patients; a mean reduction of 1.3% per day was observed among patients who received AQ+SP regardless of G6PD status (95% CI 1.25 to 1.45). Patients with G6PD deficiency recipients of CD+A had significantly lower haematocrit than the other groups until day 7 (p = 0.04). In total, 10 patients had severe post-treatment haemolysis requiring blood transfusion. Patients with G6PD deficiency showed a higher risk of severe anaemia following treatment with CD+A (RR = 10.2; 95% CI 1.8 to 59.3) or AQ+SP (RR = 5.6; 95% CI 1.0 to 32.7).
Conclusions
CD+A showed a poor safety profile in individuals with G6PD deficiency most likely as a result of dapsone induced haemolysis. Screening for G6PD deficiency before drug administration of potentially pro-oxidants drugs, like dapsone-containing combinations, although seldom available, is necessary
Moving towards greater equity in health: recent initiatives in the Lao PDR and their implications
No full text
New simple decontamination method improves microscopic detection and culture of mycobacteria in clinical practice
No full textThis study was carried out at Dr. Cetrángolo Hospital, Buenos Aires, Argentina.
The objective was to compare two digestion–decontamination procedures: the N-acetyl-Lcysteine–
sodium citrate–NaOH (NALC-NaOH) and a combination of 7% NaCl plus NaOH, the
hypertonic saline–sodium hydroxide (HS-SH) method, in detection and recovery of mycobacteria.
Microscopy detection rates before and after concentration of specimens by both methods, were also compared. The study had two phases. Phase I: comparison of the gold standard NALC-NaOH and HS-SH on paired samples involving respiratory clinical specimens by means of receiver
operating characteristic curve analysis. Phase II: blinded, randomized trial to assess the performance of HS-SH versus NALC-NaOH in clinical practice. Phase I: Positive microscopy rate was significantly increased in around 2.2% after concentration in comparison to that of specimens
without concentration. The calculated sensitivity values for microscopy detection increased between 15.2% (HS-SH: 73.5%) to 16.7% (NALC-NaOH: 75.0%) over those without concentration (58.3%). Phase II: similar diagnostic rates by microscopy and cultures were obtained by either HS-SH or NALC-NaOH. The clinical performances were also very similar. These results and the low cost of the HS-SH procedure indicate the possibility of its implementation in clinical laboratories with high burden of tuberculosis cases and low resources
Socioeconomic inequality in malnutrition in developing countries
No full textOBJECTIVE: The objectives of this study were to report on socioeconomic inequality in childhood malnutrition in the developing world, to provide evidence for an association between socioeconomic inequality and the average level of malnutrition, and to draw attention to different patterns of socioeconomic inequality in malnutrition. METHODS: Both stunting and wasting were measured using new WHO child growth standards. Socioeconomic status was estimated by principal component analysis using a set of household assets and living conditions. Socioeconomic inequality was measured using an alternative concentration index that avoids problems with dependence on the mean level of malnutrition. FINDINGS: In almost all countries investigated, stunting and wasting disproportionately affected the poor. However, socioeconomic inequality in wasting was limited and was not significant in about one third of countries. After correcting for the concentration index's dependence on mean malnutrition, there was no clear association between average stunting and socioeconomic inequality. The latter showed different patterns, which were termed mass deprivation, queuing and exclusion. Although average levels of malnutrition were higher with the new WHO reference standards, estimates of socioeconomic inequality were largely unaffected by changing the growth standards. CONCLUSION: Socioeconomic inequality in childhood malnutrition existed throughout the developing world, and was not related to the average malnutrition rate. Failure to tackle this inequality is a cause of social injustice. Moreover, reducing the overall rate of malnutrition does not necessarily lead to a reduction in inequality. Policies should, therefore, take into account the distribution of childhood malnutrition across all socioeconomic groups
Molecular tools for the rapid detection of drug resistance in animal trypanosomes
No full textThere are currently 17 African countries in which animal trypanocidal drug resistance has been reported. Large-scale surveys were carried out in only ten of them. The lack of baseline information is mainly due to the fact that the methods currently available for the detection of drug resistance are laborious, expensive and time consuming. In this review the mechanisms involved in resistance to isometamidium and diminazene will be discussed, together with some new molecular detection tools that have been developed recently enabling faster diagnosis of drug resistance than conventional laboratory or field tests
Performance characteristics and estimation of measurement uncertainty of three plating procedures for Campylobacter enumeration in chicken meat
No full textIn this work, we present an intra-laboratory study in order to estimate repeatability (r), reproducibility (R), and measurement uncertainty (U) associated with three media for Campylobacter enumeration, named, modified charcoal cefoperazone deoxycholate agar (mCCDA); Karmali agar; and CampyFood ID agar (CFA) a medium by Biomérieux SA. The study was performed at three levels: (1) pure bacterial cultures, using three Campylobacter strains; (2) artificially contaminated samples from three chicken meat matrixes (total n=30), whereby samples were spiked using two contamination levels; ca. 10(3)cfuCampylobacter/g, and ca. 10(4)cfuCampylobacter/g; and (3) pilot testing in naturally contaminated chicken meat samples (n=20). Results from pure culture experiment revealed that enumeration of Campylobacter colonies on Karmali and CFA media was more convenient in comparison with mCCDA using spread and spiral plating techniques. Based on artificially contaminated samples testing, values of repeatability (r) were comparable between the three media, and estimated as 0.15log(10)cfu/g for mCCDA, 0.14log(10)cfu/g for Karmali, and 0.18log(10)cfu/g for CFA. As well, reproducibility performance of the three plating media was comparable. General R values which can be used when testing chicken meat samples are; 0.28log(10), 0.32log(10), and 0.25log(10) for plating on mCCDA, Karmali agar, and CFA, respectively. Measurement uncertainty associated with mCCDA, Karmali agar, and CFA using spread plating, for combination of all meat matrixes, were +/-0.24log(10)cfu/g, +/-0.28log(10)cfu/g, and +/-0.22log(10)cfu/g, respectively. Higher uncertainty was associated with Karmali agar for Campylobacter enumeration in artificially inoculated minced meat (+/-0.48log(10)cfu/g). The general performance of CFA medium was comparable with mCCDA performance at the level of artificially contaminated samples. However, when tested at naturally contaminated samples, non-Campylobacter colonies gave similar deep red colour as that given by the typical Campylobacter growth on CFA. Such colonies were not easily distinguishable by naked eye. In general, the overall reproducibility, repeatability, and measurement uncertainty estimated by our study indicate that there are no major problems with the precision of the International Organization for Standardization (ISO) 10272-2:2006 protocol for Campylobacter enumeration using mCCDA medium