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Bhatt N, Karki A, Shrestha B, Singh A, Rawal LB, Sharma SK. Effectiveness of an educational intervention in improving healthcare workers' knowledge of early recognition, diagnosis and management of rheumatic fever and rheumatic heart disease in rural far-western Nepal: a pre/post-intervention study. BMJ Open 2022; 12:e059942. [PMID: 35459678 PMCID: PMC9036430 DOI: 10.1136/bmjopen-2021-059942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Rheumatic fever (RF) and rheumatic heart disease (RHD) remain among the major heart problems among children in Nepal. Although these conditions are preventable and treatable, the lack of proper knowledge and resources to diagnose and manage these conditions in rural health centres is a key concern. This study assessed the impact of educational sessions to improve the knowledge of healthcare workers in the early recognition, diagnosis, and management of RF and RHD in rural far-western Nepal. DESIGN, SETTING AND PARTICIPANTS This study used a pretest and post-test interventional design and was conducted among 64 healthcare workers in two primary healthcare centres and a peripheral district-level hospital in Achham district in the far-western region of Nepal. A self-administered questionnaire was used before and after the educational sessions. Data were analysed using SPSS V.21. RESULTS The overall test scores increased from 10 (SD=2.4) pre-intervention to 13.8 (SD=1.9) post-intervention (p<0.001). Similarly, participant confidence (graded 1-5) in differentiating bacterial from viral sore throat rose from 3.6 (SD=1.08) pre-intervention to 3.98 (SD=1.09) post-intervention (p<0.05). Confidence in managing RF increased from 3.9 (SD=0.88) pre-intervention to 4.30 (SD=0.8) post-intervention (p<0.001). CONCLUSION The findings suggest that the investigated educational sessions are promising with respect to improving the knowledge and confidence of healthcare workers in the early recognition, diagnosis, and management of RF and RHD at the primary healthcare level. Further studies with a larger sample size and conducted in different parts of the country are warranted to assess the effectiveness and impact of scaling up such educational interventions in Nepal.
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Affiliation(s)
- Navin Bhatt
- Bayalpata Hospital, Nyaya Health Nepal, Achham, Nepal
- Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | - Ashmita Karki
- Central Department of Public Health, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | | | - Amul Singh
- Bayalpata Hospital, Nyaya Health Nepal, Achham, Nepal
| | - Lal B Rawal
- School of Health, Medical and Applied Sciences, College of Science and Sustainability, Central Queensland University, Sydney, New South Wales, Australia
| | - Sanjib Kumar Sharma
- Department of Internal Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
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Abstract
Primarily affecting the young, rheumatic heart disease (RHD) is a neglected chronic disease commonly causing premature morbidity and mortality among the global poor. Standard clinical prevention and treatment is based on studies from the early antimicrobial era, as research investment halted soon after the virtual eradication of the disease from developed countries. The emergence of new global data on disease burden, new technologies, and a global health equity platform have revitalized interest and investment in RHD. This review surveys past and current evidence for standard RHD diagnosis and treatment, highlighting gaps in knowledge.
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Affiliation(s)
- Shanti Nulu
- Section of Cardiovascular Medicine, Yale School of Medicine, 789 Howard Avenue, New Haven, CT 06519, USA
| | - Gene Bukhman
- Division of Global Health Equity, Brigham and Women's Hospital, 641 Huntington Avenue, Boston, MA 02115, USA; Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Gene F Kwan
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA; Section of Cardiovascular Medicine, Boston University Medical Center, Boston University School of Medicine, 88 East Newton Street, D8, Boston, MA 02118, USA.
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Enarson PM, Gie RP, Mwansambo CC, Maganga ER, Lombard CJ, Enarson DA, Graham SM. Reducing deaths from severe pneumonia in children in Malawi by improving delivery of pneumonia case management. PLoS One 2014; 9:e102955. [PMID: 25050894 PMCID: PMC4106861 DOI: 10.1371/journal.pone.0102955] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 06/26/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To evaluate the pneumonia specific case fatality rate over time following the implementation of a Child Lung Health Programme (CLHP) within the existing government health services in Malawi to improve delivery of pneumonia case management. METHODS A prospective, nationwide public health intervention was studied to evaluate the impact on pneumonia specific case fatality rate (CFR) in infants and young children (0 to 59 months of age) following the implementation of the CLHP. The implementation was step-wise from October 1st 2000 until 31st December 2005 within paediatric inpatient wards in 24 of 25 district hospitals in Malawi. Data analysis compared recorded outcomes in the first three months of the intervention (the control period) to the period after that, looking at trend over time and variation by calendar month, age group, severity of disease and region of the country. The analysis was repeated standardizing the follow-up period by using only the first 15 months after implementation at each district hospital. FINDINGS Following implementation, 47,228 children were admitted to hospital for severe/very severe pneumonia with an overall CFR of 9.8%. In both analyses, the highest CFR was in the children 2 to 11 months, and those with very severe pneumonia. The majority (64%) of cases, 2-59 months, had severe pneumonia. In this group there was a significant effect of the intervention Odds Ratio (OR) 0.70 (95%CI: 0.50-0.98); p = 0.036), while in the same age group children treated for very severe pneumonia there was no interventional benefit (OR 0.97 (95%CI: 0.72-1.30); p = 0.8). No benefit was observed for neonates (OR 0.83 (95%CI: 0.56-1.22); p = 0.335). CONCLUSIONS The nationwide implementation of the CLHP significantly reduced CFR in Malawian infants and children (2-59 months) treated for severe pneumonia. Reasons for the lack of benefit for neonates, infants and children with very severe pneumonia requires further research.
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Affiliation(s)
- Penelope M. Enarson
- Child Lung Health Division, International Union Against Tuberculosis and Lung Disease, Paris, France
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Robert P. Gie
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg, South Africa
| | | | | | - Carl J. Lombard
- Biostatistics Unit, South Africa Medical Research Council (MRC), Cape Town, South Africa
| | - Donald A. Enarson
- Child Lung Health Division, International Union Against Tuberculosis and Lung Disease, Paris, France
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Stephen M. Graham
- Child Lung Health Division, International Union Against Tuberculosis and Lung Disease, Paris, France
- Centre for International Child Health, University of Melbourne Department of Paediatrics and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
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Curry LA, Luong MA, Krumholz HM, Gaddis J, Kennedy P, Rulisa S, Taylor L, Bradley EH. Achieving large ends with limited means: grand strategy in global health. Int Health 2013; 2:82-6. [PMID: 24037468 DOI: 10.1016/j.inhe.2010.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Unprecedented attention is focused on global health, with a four-fold increase in development assistance in the last 15 years and the scope of global health expanding beyond infectious disease to include chronic disease and health systems strengthening. As the global impact of health is more widely understood, it has become a crucial element of international relations, economic development, and foreign affairs. At this potential leverage point in the global health movement, the application of grand strategy is of critical importance. Grand strategy, i.e., the development and implementation of comprehensive plans of action to achieve large ends with limited means, has been refined through centuries of international relations and the management of states but has been inadequately applied to global health policy and implementation. We review key principles of grand strategy and demonstrate their applicability to a central global health issue: maternal mortality. The principles include: start with the end in mind, take an ecological approach, recognize that tactics matter, use positive deviance to characterize practical solutions and foster scale-up, and integrate timely intelligence and data into health interventions and improvement efforts. We advocate for the greater use of grand strategy in global health.
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Affiliation(s)
- Leslie A Curry
- Yale School of Public Health, 60 College Street, New Haven, CT 06520, USA
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Jones DS, Greene JA. The decline and rise of coronary heart disease: understanding public health catastrophism. Am J Public Health 2013; 103:1207-18. [PMID: 23678895 PMCID: PMC3682614 DOI: 10.2105/ajph.2013.301226] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2012] [Indexed: 11/04/2022]
Abstract
The decline of coronary heart disease mortality in the United States and Western Europe is one of the great accomplishments of modern public health and medicine. Cardiologists and cardiovascular epidemiologists have devoted significant effort to disease surveillance and epidemiological modeling to understand its causes. One unanticipated outcome of these efforts has been the detection of early warnings that the decline had slowed, plateaued, or even reversed. These subtle signs have been interpreted as evidence of an impending public health catastrophe. This article traces the history of research on coronary heart disease decline and resurgence and situates it in broader narratives of public health catastrophism. Juxtaposing the coronary heart disease literature alongside the narratives of emerging and reemerging infectious disease helps to identify patterns in how public health researchers create data and craft them into powerful narratives of progress or pessimism. These narratives, in turn, shape public health policy.
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Affiliation(s)
- David S Jones
- Department of History of Science, Harvard University, Cambridge, MA, USA.
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Kwan GF, Bukhman AK, Miller AC, Ngoga G, Mucumbitsi J, Bavuma C, Dusabeyezu S, Rich ML, Mutabazi F, Mutumbira C, Ngiruwera JP, Amoroso C, Ball E, Fraser HS, Hirschhorn LR, Farmer P, Rusingiza E, Bukhman G. A simplified echocardiographic strategy for heart failure diagnosis and management within an integrated noncommunicable disease clinic at district hospital level for sub-Saharan Africa. JACC-HEART FAILURE 2013; 1:230-6. [PMID: 24621875 DOI: 10.1016/j.jchf.2013.03.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 03/28/2013] [Accepted: 03/28/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study sought to describe a decentralized strategy for heart failure diagnosis and management and report the clinical epidemiology at district hospitals in rural Rwanda. BACKGROUND Heart failure contributes significantly to noncommunicable disease burden in sub-Saharan Africa. Specialized care is provided primarily at referral hospitals by physicians, limiting patients' access. Simplifying clinical strategies can facilitate decentralization of quality care to the district hospital level and improve care delivery. METHODS Heart failure services were established within integrated advanced noncommunicable disease clinics in 2 rural district hospitals in Rwanda. Nurses, supervised by physicians, were trained to use simplified diagnostic and treatment algorithms including echocardiography with diagnoses confirmed by a cardiologist. Data on 192 heart failure patients treated between November 2006 and March 2011 were reviewed from an electronic medical record. RESULTS In our study population, the median age was 35 years, 70% were women, 63% were subsistence farmers, and 6% smoked tobacco. At entry, 47% had New York Heart Association class III or IV functional status. Of children age <18 years (n = 54), rheumatic heart disease (48%), congenital heart disease (39%), and dilated cardiomyopathy (9%) were the leading diagnoses. Among adults (n = 138), dilated cardiomyopathy (54%), rheumatic heart disease (25%), and hypertensive heart disease (8%) were most common. During follow-up, 62% were retained in care, whereas 9% died and 29% were lost to follow-up. CONCLUSIONS In rural Rwanda, the causes of heart failure are almost exclusively nonischemic even though patients often present with advanced symptoms. Training nurses, supervised by physicians, in simplified protocols and basic echocardiography is 1 approach to integrated, decentralized care for this vulnerable population.
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Affiliation(s)
- Gene F Kwan
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Section of Cardiology, Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Alice K Bukhman
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ann C Miller
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | | | | | - Charlotte Bavuma
- Inshuti Mu Buzima, Rwinkwavu, Rwanda; Department of Internal Medicine, Endocrinology Unit, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda; Ministry of Health, Kigali, Rwanda
| | | | - Michael L Rich
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Partners In Health, Boston, Massachusetts
| | | | | | | | - Cheryl Amoroso
- Inshuti Mu Buzima, Rwinkwavu, Rwanda; Partners In Health, Boston, Massachusetts
| | - Ellen Ball
- Partners In Health, Boston, Massachusetts
| | - Hamish S Fraser
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Partners In Health, Boston, Massachusetts
| | - Lisa R Hirschhorn
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Partners In Health, Boston, Massachusetts
| | - Paul Farmer
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Partners In Health, Boston, Massachusetts
| | - Emmanuel Rusingiza
- Inshuti Mu Buzima, Rwinkwavu, Rwanda; Ministry of Health, Kigali, Rwanda; Department of Pediatrics, Pediatric Cardiology Unit, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda
| | - Gene Bukhman
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Ministry of Health, Kigali, Rwanda; Partners In Health, Boston, Massachusetts; VA Boston Healthcare System, Boston, Massachusetts.
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Davidson PM, Meleis AI, McGrath SJ, DiGiacomo M, Dharmendra T, Puzantian HV, Song M, Riegel B. Improving women's cardiovascular health: a position statement from the International Council on Women's Health Issues. Health Care Women Int 2012; 33:943-55. [PMID: 22946595 DOI: 10.1080/07399332.2011.646375] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Cardiovascular disease (CVD) is the number one killer of women worldwide, and it remains the primary cause of death and disability in both developed and developing countries. The International Council on Women's Health Issues is an international nonprofit association dedicated to the goals of promoting the health, health care, and the well-being of women. Based on the outcomes of a facilitated discussion at its 18th biannual meeting, delegates aim to raise awareness about the potent influence of gender-specific factors on the development, progression, and outcomes of CVD. Key recommendations for decreasing the burden of CVD are also discussed.
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Affiliation(s)
- Patricia M Davidson
- Centre for Cardiovascular and Chronic Care, University of Technology, Broadway, New South Wales, Australia.
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Moolani Y, Bukhman G, Hotez PJ. Neglected tropical diseases as hidden causes of cardiovascular disease. PLoS Negl Trop Dis 2012; 6:e1499. [PMID: 22745835 PMCID: PMC3383757 DOI: 10.1371/journal.pntd.0001499] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- Yasmin Moolani
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States of America
| | - Gene Bukhman
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Peter J. Hotez
- Sabin Vaccine Institute and Texas Children's Center for Vaccine Development, Department of Pediatrics (Section of Pediatric Tropical Medicine) and Molecular Virology & Microbiology, National School of Tropical Medicine, Baylor College of Medicine, Houston, Texas, United States of America
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Shakow AD, Bukhman G, Adebona O, Greene J, De Dieu Ngirabega J, Binagwaho A. Transforming South–South Technical Support to Fight Noncommunicable
Diseases. Glob Heart 2012; 7:35-45. [DOI: 10.1016/j.gheart.2012.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Enarson PM, Gie R, Enarson DA, Mwansambo C. Development and implementation of a national programme for the management of severe and very severe pneumonia in children in Malawi. PLoS Med 2009; 6:e1000137. [PMID: 19901978 PMCID: PMC2766047 DOI: 10.1371/journal.pmed.1000137] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Penelope Enarson and colleagues describe the development, scale-up, and achievements of a national pneumonia program in Malawi, which is based on a successful anti-tuberculosis service delivery model.
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Affiliation(s)
- Penelope Marjorie Enarson
- International Union Against Tuberculosis and Lung Disease, Child Lung Health Division, Paris, France.
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