Decision-making process of Kala Azar care: results from a qualitative study carried out in disease endemic areas of Nepal

Risk, trust and patients' strategic choices of healthcare practitioners

Research on patients' choice of healthcare practitioners has focussed on countries with regulated and controlled healthcare markets. In contrast, low- and middle-income countries have a pluralistic landscape where untrained, unqualified and unlicensed informal healthcare providers (IHPs) provide significant share of services. Using qualitative data from 58 interviews in an Indian village, this paper explores how patients choose between IHPs and qualified practitioners in the public and formal private sectors. The study found that patients' choices were structurally constrained by accessibility and affordability of care and choosing a practitioner from any sector presented some risk. Negotiation and engagement with risks depended on perceived severity of the health condition and trust in practitioners. Patients had low institutional trust in public and formal private sectors, whereas IHPs operated outside any institutional framework. Consequently, people relied on relational or competence-derived interpersonal trust. Care was sought from formal private practitioners for severe issues due to high-competence-based interpersonal trust in them, whereas for other issues IHPs were preferred due to high relationship-based interpersonal trust. The research shows that patients develop a strategic approach to practitioner choice by using trust to negotiate risks, and crucially, in low- and middle-income countries IHPs bridge a gap by providing accessible and affordable care imbued with relational-interpersonal trust.

Understanding challenges to malaria elimination in Nepal: a qualitative study with an embedded capacity-building exercise

Background

The Nepalese Government has made significant progress toward the elimination of malaria. However, given the surge in the prevalence of non-communicable diseases, such as diabetes and hypertension, and the localized nature of malaria prevalence, malaria elimination will remain a challenge. In the current study, the authors sought to understand local perceptions on threats to malaria elimination in three endemic districts.

Methods

The authors conducted a capacity-building exercise embedded within a qualitative study. The study component aimed to understand how local policymakers and actors perceive challenges in malaria elimination. For them to be able to articulate the challenges, however, an understanding of malaria elimination in the context of a broader health system in Nepal would be required. The capacity-building component, thus, involved providing that knowledge.

Results

Although the prevalence of malaria is high in the three districts where the study was conducted, there are significant gaps in human resources, diagnosis and treatment, and the provision of indoor residual spraying and long-lasting insecticide treated nets. More importantly, the authors’ experience suggests that it may be possible to capitalize on local expertise in order to identify gaps in malaria elimination at a sub-national level by building in a capacity-building exercise within a study.

Conclusions

Locals in three malaria-endemic districts of Nepal perceive that there are significant gaps in human resources, diagnosis and treatment, the provision of insecticide treated nets, and indoor residual spraying.

Effect of an mHealth Intervention to Improve Health Literacy in Immigrant Populations: A Quasi-experimental Study

Health literacy is a social determinant of the basic health of populations and is especially important to enhancing and developing the empowerment of migrant populations. To evaluate the effectiveness of an mHealth intervention to improve the cognitive and social skills that enable migrants to access and use health services, we developed a quasi-experimental design to encompass a single group of enrolled immigrants (N = 93). They completed preintervention and postintervention questionnaires of the European Health Literacy Survey Questionnaire, the self-created questionnaire HL-APP-Q14 (Health Literacy App Questionnaire), and a practical simulation test. Health literacy improved significantly after the intervention, increasing from a problematic level (mean, 9.55 [SD, 4.35]) to a sufficient level (mean, 14.03 [SD, 2.68]). Differences were statistically significant for males and females as well as for participants of all nationalities, except the Chinese group. The application e_SaludAble empowered the migrant participants through the improvement of their health literacy.

[Priority setting and rationing of pharmaceuticals - an experimental analysis of discussion processes]

BACKGROUND/OBJECTIVE

In the face of rising expenditure among statutory sickness funds in Germany it is necessary to start a discussion about priority setting in the healthcare system. For a long time this issue has been avoided in healthcare debates. As a result, normative directives are still missing, which can lead to priority setting among healthcare providers in daily healthcare practice. Prioritization can be conducted at three different levels: at the government (macro), the institutional (meso), and the patient (micro) level. Surveys about societal preferences for different criteria exist; however, specifications on their respective weighting in the situation of approval and reimbursement of pharmaceuticals (meso) are missing. For this reason, the present study analyzed the implementation and weighting of the criteria for priority setting at the meso level, taking values and experiences of the participants into account.

METHOD

Six qualitative focus groups were carried out with representatives from the fields of medicine, ethics, public health and economics. During the discussions four fictitious drugs for the treatment of different lung diseases were prioritized based on guidelines. The discussion processes were analyzed according to Bohnsack's documentary method.

RESULTS

The criteria "quality of life", "life expectancy" and "other patient-relevant outcomes" were discussed in relation to each other. The evaluation of change in patient-relevant outcomes was difficult to perform for non-medical participants. The second argument concerned the criteria "costs", disease severity and "number of patients". Costs were given less weight, but were often used to support other criteria. Other challenges in reaching a consensus included emerging role conflicts between profession and personal opinion, and the transfer of the discussion to a different level of decision-making.

DISCUSSION

In the discussions the problem of prioritizing did not arise from different preferences for prioritization criteria, but from the weighting of the criteria. The operationalization of the criteria seemingly depends on the decision-making situation, the participants' personal connection with the relevant disease and on the correspondence between evidence and personal experiences.

Combating infectious diseases of poverty: a year on

The Infectious Diseases of Poverty journal, launched a year ago, is a platform to engage outside the traditional disciplinary boundaries, and disseminate high quality science towards the improvement of health. This paper reviews the milestone achievements during its first year of operation. The journal has filled an important niche, addressing some of the main priorities in the Global Report for Research on Infectious Diseases of Poverty. Highlights include the publication of three thematic issues on health systems, surveillance and response systems, as well as co-infection and syndemics. The thematic issues have foregrounded the importance and innovation that can be achieved through transdisciplinary research. The journal has been indexed by PubMed since April 2013, with the publication of a total of 38 articles. Finally, the journal is delivering to wider range readers both in developing and developed countries with sustained efforts with a focus on relevant and strategic information towards elimination of infectious diseases of poverty.