35 research outputs found
Quality of care for children with acute malnutrition at health center level in Uganda: a cross sectional study in West Nile region during the refugee crisis
No full textBackground: Arua district, in Uganda, hosts some of the largest refugee camps in the country. The estimated prevalence of moderate and severe acute malnutrition in children is higher than the national estimates (10.4 and 5.6% respectively, compared to 3.6 and 1.3%). This study aimed at assessing the quality of care provided to children with acute malnutrition at out-patient level in such a setting.
Methods: Six facilities with the highest number of children with malnutrition were selected. The main tool used was the National Nutrition Service Delivery Assessment Tool, assessing 10 key areas of service delivery and assigned a score as either poor, fair, good or excellent. Health outcomes, quality of case management and data quality were assessed from the health management information system and from the official nutrition registers.
Results: All facilities except two scored either poor or fair under all the 10 assessment areas. Overall, 33/60 (55%) areas scored as poor, 25/60 (41%) as fair, 2/60 (3.3%) as good, and none as excellent. Main gaps identified included: lack of trained staff; disorganised patient flow; poor case management; stock out of essential supplies including ready-to-use therapeutic foods; weak community linkage. A sample coverage of 45.4% (1020/2248) of total children admitted in the district during the 2016 financial year were included. The overall mean cure rate was 52.9% while the default rate was 38.3%. There was great heterogeneity across health facilities in health outcomes, quality of case management, and data quality.
Conclusion: This study suggests that quality of care provided to children with malnutrition at health center level is substandard with unacceptable low cure rates. It is essential to identify effective approaches to enhance adherence to national guidelines, provision of essential nutritional commodities, regular monitoring of services and better linkage with the community through village health teams
The hidden burden of measles in Ethiopia: how distance to hospital shapes the disease mortality rate
No full textAbstract Background A sequence of annual measles epidemics has been observed from January 2013 to April 2017 in the South West Shoa Zone of the Oromia Region, Ethiopia. We aimed at estimating the burden of disease in the affected area, taking into account inequalities in access to health care due to travel distances from the nearest hospital. Methods We developed a dynamic transmission model calibrated on the time series of hospitalized measles cases. The model provided estimates of disease transmissibility and incidence at a population level. Model estimates were combined with a spatial analysis to quantify the hidden burden of disease and to identify spatial heterogeneities characterizing the effectiveness of the public health system in detecting severe measles infections and preventing deaths. Results A total of 1819 case patients and 36 deaths were recorded at the hospital. The mean age was 6.0 years (range, 0–65). The estimated reproduction number was 16.5 (95% credible interval (CI) 14.5–18.3) with a cumulative disease incidence of 2.34% (95% CI 2.06–2.66). Three thousand eight hundred twenty-one (95% CI 1969–5671) severe cases, including 2337 (95% CI 716–4009) measles-related deaths, were estimated in the Woliso hospital’s catchment area (521,771 inhabitants). The case fatality rate was found to remarkably increase with travel distance from the nearest hospital: ranging from 0.6% to more than 19% at 20 km. Accordingly, hospital treatment prevented 1049 (95% CI 757–1342) deaths in the area. Conclusions Spatial heterogeneity in the access to health care can dramatically affect the burden of measles disease in low-income settings. In sub-Saharan Africa, passive surveillance based on hospital admitted cases might miss up to 60% of severe cases and 98% of related deaths
Effect of a Low-Dose/High-Frequency Training on Real-Life Neonatal Resuscitation in a Low-Resource Setting
No full textBackground: As intrapartum-related events represent a quarter of all neonatal deaths, education on neonatal resuscitation is a critical priority. Objective: To assess the impact of a low-dose/high-frequency neonatal resuscitation training on clinical practice of midwives in a low-resource setting. Methods: Eight months after a modified Neonatal Resuscitation Program (NRP) course, we implemented a low-dose/high-frequency training for midwives at Beira Central Hospital, Mozambique. The training lasted 6 months and included weekly practice sessions. Fifty consecutive resuscitations after the low-dose/high-frequency training were compared with those registered before (n = 50) and after (n = 50) participation in the adapted NRP course using video recording. Results: All 150 neonates received the initial steps; 103 required bag-mask ventilation and 41 required chest compressions. The scores for initial steps, bag-mask ventilation and chest compressions improved after the course (p < 0.0001, p = 0.005 and p = 0.03) and did not change after the low-dose/high-frequency training (p = 0.34, p = 0.99 and p = 0.30). The low-dose/high-frequency training decreased the total time of the procedure (p < 0.0001) and anticipated start time of airway suctioning and tactile stimulation (p = 0.003 and p < 0.0001), but had no effect on the time of initiation of bag-mask ventilation (p = 0.30). Conclusions: In a low- income setting, a low-dose/high-frequency training after participation in an adapted NRP course contributed to improving the initiation and times of some procedures. However, many aspects of neonatal resuscitation remained poor. Low-dose/high-frequency training should focus on improving the prevention of thermal loss, face mask ventilation and heart rate assessment
Thermal effect of a woolen cap in low birth weight infants during kangaroo care
No full textBACKGROUND AND OBJECTIVES: World Health Organization guidelines recommend covering the head during kangaroo mother care (KMC), but the effect of a cap on neonatal thermal control during KMC remains to be defined. Our objective was to assess the effectiveness and safety of a woolen cap in maintaining low birth weight infants (LBWIs) in normal thermal range during KMC. METHODS: Three hundred LBWI candidates for KMC in 3 African hospitals were randomly assigned to KMC with (CAP group) or without (NOCAP group) a woolen cap in a 1:1 ratio during the first week after birth. Axillary temperature was measured every 6 hours. Maternal and room temperature and adherence to skin-to-skin contact were registered at the same time points. RESULTS: A total number of 5064 measurements were recorded (median 19 measurements per subject; interquartile range: 10–25). Mean time spent in normal temperature range was 55% (SD 24) in CAP and 56% (SD 24) in NOCAP groups. Multivariable analysis estimated a rate ratio of 0.92 (95% confidence interval: 0.84 to 1.00; P = .06) for the effect of the cap versus no cap on time spent in the normal temperature range. CONCLUSIONS: In these 3 African, low-resource settings and so many days post birth, the use of a woolen cap was safe but provided no advantages in maintaining LBWI in the normal thermal range while being in a KMC ward. LBWIs spent only half of the time in the normal temperature range despite warm rooms and skin-to-skin contact. Maintaining normothermia in LBWIs remains an unfinished challenge in low-resource settings
Social determinants of therapy failure and multi drug resistance among people with tuberculosis: A review
No full textBackground Social determinants influence health and the development of tuberculosis (TB). However, a paucity of data is available considering the relationship of social determinants influencing therapy failure and multi drug resistance (MDR). We conducted a review investigating the relationship of common social determinants on therapy failure and MDR in people with TB. Methods PubMed and SCOPUS were searched without language restrictions until February 02, 2016 for studies reporting the association between socioeconomic factors (income, education and alcohol abuse) and therapy failure or MDR-TB. The association between social determinants and outcomes was explored by pooling data with a random effects model and calculating crude and adjusted odds ratios (ORs) ±95% confidence intervals (CIs). Results Fifty studies with 407,555 participants with TB were included. Analysis demonstrated that low income (unadjusted OR = 2.00 (95% CI: 1.69–2.38; I2 = 88%; 33 studies, adjusted OR 1.77, p < 0.0001), low education (unadjusted OR 2.11, 95% CI 1.55–2.86, 26 studies, adjusted OR 1.69, p < 0.0001) and alcohol abuse (unadjusted OR = 2.43 (95% CI: 1.56–3.80, 16 studies, adjusted OR 2.13, p < 0.0001) were associated with therapy failure. Similarly, low income (unadjusted OR = 1.67; 95% CI: 1.12–2.41, p = 0.006; 14 studies, adjusted OR 2.16, p < 0.0001) and alcohol abuse (unadjusted OR = 1.88; 95% CI: 1.18–3.00, 7 studies, adjusted OR 1.43, p = 0.06) were associated with MDR-TB. Increasing age of the population was able to explain a consistent part of the heterogeneity found
User-only design to assess drug effectiveness in clinical practice: application to bisphosphonates and secondary prevention of fractures.
No full textPURPOSE:
Different strategies applicable to control for confounding by indication in observational studies were compared in a large population-based study regarding the effect of bisphosphonates (BPs) for secondary prevention of fractures.
METHODS:
The cohort was drawn from healthcare utilization databases of 13 Italian territorial units. Patients aged 55 years or more who were hospitalized for fracture during 2003-2005 entered into the cohort. A nested case-control design was used to compare BPs use in cohort members who did (cases) and who did not experience (controls) a new fracture until 2007 (outcome). Three designs were employed: conventional-matching (D1 ), propensity score-matching (D2 ), and user-only (D3 ) designs. They differed for (i) cohort composition, restricted to patients who received BPs straight after cohort entry (D3 ); (ii) using propensity score for case-control matching (D2 ); and (iii) compared groups of BPs users versus no users (D1 and D2 ) and long-term versus short-term users (D3 ).
RESULTS:
Bisphosphonate users had odds ratios (95% confidence interval) of 1.20 (1.01 to 1.44) and 0.95 (0.74 to 1.24) by applying D1 and D2 designs, respectively. Statistical evidence that long-term BPs use protects the outcome onset with respect to short-term use was observed for user-only design (D3 ) being the corresponding odds ratio (95% confidence interval) 0.64 (0.44 to 0.93).
CONCLUSIONS:
User-only design yielded closer results to those seen in RCTs. This approach is one possible strategy to account for confounding by indication
Is a woolen cap effective in maintaining normothermia in low-birth-weight infants during kangaroo mother care? Study protocol for a randomized controlled trial
No full textBackground: Neonatal hypothermia is an important challenge associated with morbidity and mortality. Preventing neonatal hypothermia is important in high-resource countries, but is of fundamental importance in low-resource settings where supportive care is limited. Kangaroo mother care (KMC) is a low-cost intervention that, whenever possible, is strongly recommended for temperature maintenance. During KMC, the World Health Organization (WHO) guidelines recommend the use of a cap/hat, but its effect on temperature control during KMC remains to be established. In the hospitals participating in the projects of the non-governmental organization CUAMM, KMC represents a standard of care, but the heads of the babies often remain uncovered due to local habits or to the unavailability of a cap. The aim of the present study will be to assess the effectiveness and safety of using a woolen cap in maintaining normothermia in low-birth-weight infants (LBWI) during KMC. Methods/design: This is a multicenter (three hospitals), multicountry (three countries), prospective, unblinded, randomized controlled trial of KMC treatment with and without a woolen cap in LBWI. After obtaining parental consent, all infants with a birth weight below 2500g and who are candidates for KMC, based on the clinical decision of the attending physician, will be assigned to the KMC with a woolen cap group or to the KMC without a woolen cap group in a 1:1 ratio according to a computer-generated, randomized sequence. The duration of the study will be until the patient's discharge, with a maximum treatment duration of 7days. The primary outcome measure will be whether the infants' temperatures remain within the normal range (36.5-37.5°C) in the course of KMC during the intervention. In all participants, axillary temperature will be measured with a digital thermometer four times per day. In addition, maternal and room temperature will be recorded. Secondary outcome measures will be: episodes of apnea; sepsis; mortality before hospital discharge in-hospital growth; and age at discharge. Discussion: The findings of this study will be important for other units/settings in high- as well low-resource countries where KMC is routinely performed. Based on the results of the present study, we could speculate whether the use of a woolen cap may help to maintain the neonate within the normal thermal range. Furthermore, potential complications such as hyperthermia will be strictly monitored and collected. Trial registration: ClinicalTrials.gov Identifier: NCT02645526(registered on 31 December 2015)
Neonatal resuscitation using a supraglottic airway device for improved mortality and morbidity outcomes in a low-income country: Study protocol for a randomized trial
No full textBackground: Intrapartum-related death is the third leading cause of under-5 mortality. Effective ventilation during neonatal resuscitation has the potential to reduce 40% of these deaths. Face-mask ventilation performed by midwives is globally the most common method of resuscitating neonates. It requires considerable operator skills and continuous training because of its complexity. The i-gel® is a cuffless supraglottic airway which is easy to insert and provides an efficient seal that prevents air leakage; it has the potential to enhance performance in neonatal resuscitation. A pilot study in Uganda demonstrated that midwives could safely resuscitate newborns with the i-gel® after a short training session. The aim of the present trial is to investigate whether the use of a cuffless supraglottic airway device compared with face-mask ventilation during neonatal resuscitation can reduce mortality and morbidity in asphyxiated neonates. Methods: A randomized phase III open-label superiority controlled clinical trial will be conducted at Mulago Hospital, Kampala, Uganda, in asphyxiated neonates in the delivery units. Prior to the intervention, health staff performing resuscitation will receive training in accordance with the Helping Babies Breathe curriculum with a special module for training on supraglottic airway insertion. A total of 1150 to 1240 babies (depending on cluster size) that need positive pressure ventilation and that have an expected gestational age of more than 34 weeks and an expected birth weight of more than 2000 g will be ventilated by daily unmasked randomization with a supraglottic airway device (i-gel®) (intervention group) or with a face mask (control group). The primary outcome will be a composite outcome of 7-day mortality and admission to neonatal intensive care unit (NICU) with neonatal encephalopathy. Discussion: Although indications for the beneficial effect of a supraglottic airway device in the context of neonatal resuscitation exist, so far no large studies powered to assess mortality and morbidity have been carried out. We hypothesize that effective ventilation will be easier to achieve with a supraglottic airway device than with a face mask, decreasing early neonatal mortality and brain injury from neonatal encephalopathy. The findings of this trial will be important for low and middle-resource settings where the majority of intrapartum-related events occur
Participants' opinions of the limited impact of an adapted neonatal resuscitation course in a low‐resource setting
No full textSupportive supervision to improve the quality and outcome of outpatient care among malnourished children: a cluster randomised trial in Arua district, Uganda
No full textIntroduction Suboptimal quality of paediatric care has been reported in resource-limited settings, but little evidence exists on interventions to improve it in such settings. This study aimed at testing supportive supervision (SS) for improving health status of malnourished children, quality of case management, overall quality of care, and the absolute number of children enrolled in the nutritional services.Methods This was a cluster randomised trial conducted in Arua district. Six health centres (HCs) with the highest volume of work were randomised to either SS or no intervention. SS was delivered by to HCs staff (phase 1), and later extended to community health workers (CHWs) (phase 2). The primary outcome was the cure rate, measured at children level. Quality of case management was assessed by six pre-defined indicators. Quality of care was assessed using the national Nutrition Service Delivery Assessment (NSDA) tool. Access to care was estimated with the number of children accessing HC nutritional services.Results Overall, 737 children were enrolled. In the intervention arm, the cure rate (83.8% vs 44.9%, risk ratio (RR)=1.91, 95% CI: 1.56–2.34, p=0.001), quality of care as scored by NSDA (RR=1.57, 95% CI: 1.01–2.44, p=0.035) and correctness in complementary treatment (RR=1.52, 95% CI: 1.40–1.67, p=0.001) were significantly higher compared with control. With the extension of SS to CHWs (phase 2), there was a significant 38.6% more children accessing care in the intervention HCs (RR=1.26, 95% CI: 1.11–1.44, p=0.001) compared with control.Conclusion SS significantly improved the cure rate of malnourished children, and the overall quality of care, SS to CHWs significantly increased the crude number of children enrolled in the nutritional services. More studies should confirm these results, and evaluate the cost-effectiveness of SS
