Risk behaviours and AIDS knowledge in a rural community of Senegal: relationship with sources of AIDS information

BACKGROUND

The objective of this paper is to describe sources of information on HIV/AIDS and their relationship with AIDS-related knowledge and sexual behaviour in a rural area of south Senegal.

METHODS

A cross-sectional study using a standardized questionnaire was administered in 1994 by local interviewers to 240 men and 242 women aged 15-59 years, randomly selected from the general population.

RESULTS

Sources of HIV/AIDS information most frequently cited were radio for men (61% of men) and the local health centre for women (52% of women). Among men, citing radio as a source of information was associated with an improved overall AIDS-related knowledge (a seven-questions based average score was 4.30 for men citing radio acquired information and 5.90 for men not citing radio acquired information; P < 10(-4)) and was associated with a smaller number of casual sexual partners in the 12 months preceding the interview (1.94 versus 1.48; P = 0.04). Women citing the local health centre as a source of HIV/AIDS information had a better perception of condom use and more often felt threatened by HIV/AIDS, but did not declare a significantly different number of casual sex partners in the 12 months preceding the interview. Television as a source was cited by 42% of men and 33% of women and was associated with an increased AIDS-knowledge score for men, with a smaller number of casual sex partners for women and with better perception of condoms for men.

CONCLUSION

Because of its large spread and impact, radio appears to be an efficient way to reduce risk-taking behaviour among men. In addition, it is a very convenient way to reach people with high mobility such as male seasonal migrants. For women, attendance at health centres for maternity purposes is an opportunity to receive prevention messages. Finally, numerous men and women have had the opportunity to watch television when they are in towns during the migration period. This method seems to deliver effective messages.

Noncommunicable disease management in resource-poor settings: a primary care model from rural South Africa

Noncommunicable diseases (NCDs) such as hypertension, asthma, diabetes and epilepsy are placing an increasing burden on clinical services in developing countries and innovative strategies are therefore needed to optimize existing services. This article describes the design and implementation of a nurse-led NCD service based on clinical protocols in a resource-poor area of South Africa. Diagnostic and treatment protocols were designed and introduced at all primary care clinics in the district, using only essential drugs and appropriate technology; the convenience of management for the patient was highlighted. The protocols enabled the nurses to control the clinical condition of 68% of patients with hypertension, 82% of those with non-insulin-dependent diabetes, and 84% of those with asthma. The management of NCDs of 79% of patients who came from areas served by village or mobile clinics was transferred from the district hospital to such clinics. Patient-reported adherence to treatment increased from 79% to 87% (P = 0.03) over the 2 years that the service was operating. The use of simple protocols and treatment strategies that were responsive to the local situation enabled the majority of patients to receive convenient and appropriate management of their NCD at their local primary care facility.

Packaged treatment for first-line care in cerebral malaria and meningitis

Described are the results of a trial carried out from January to June 1996 in southern Malawi to determine the effectiveness of a treatment pack for infants and children under the age of 6 years, who presented as emergencies to rural health centres with presumptive diagnoses of severe/cerebral malaria or meningitis. Each complete treatment pack (approximate cost, US$ 6) contained, inter alia, intramuscular quinine, intramuscular choloramphenicol, dextrose, paraldehyde, a nasogastric tube, prepacked syringes, and sterile water. A modified coma score and drug dosage nomogram were also included in the package. Despite a considerable drop in overall mortality, problems arose with regard to the incomplete treatment of possible meningitis and in the development of a rational referral policy.

Assessment of rational drug use and prescribing in primary health care facilities in north west Ethiopia

A study on rational drug use was undertaken in nine health centres (HCs) and nine health stations (HSs) in Ethiopia. Prescribing, patient care and facility specific factors were measured using drug use indicators. Prescribing patterns of drugs were also assessed. With only few exceptions, the drug use indicators in HCs and HSs and between retrospective and prospective studies were similar despite differences in manpower and facilities. The average consultation time (in minutes) in HSs and HCs was 5.1 +/- 0.8 and 5.8 +/- 1.06, respectively. The dispensing time (in minutes) was 1.5 +/- 0.7 in HSs and 1.9 +/- 0.6 in HCs. Both patient care indicators seem to be adequate to influence patient satisfaction to the overall health service and patient knowledge of important dosage instructions. Most drugs (more than 89% in HCs and 71% in HSs) were actually dispensed from the health facilities and labelling was satisfactory. Prescribing by generic names (average: 75% in HCs and 83% in HSs) was encouraging. While the availability of key drugs was ensured, essential documents were missing in most facilities or they were unpopular for use, and those available required revision and updating. Polypharmacy in which the number of drugs/encounter was < 2.5 was minimal, but that a large proportion of the prescriptions contained two or more drugs could result in adverse drug-drug interactions. The most frequently prescribed drugs were anti-infectives and analgesics accounting for over 76% in HCs and 82% in HSs and in most cases they are probably prescribed with little justification. The exposure of patients to antibiotics (average: 60% in HCs and 65% in HSs) was unacceptably high to justify epidemiological trends. The high exposure of patients to injections, especially in the HSs (over 37%), should be seen from the health and economic points of view. The results revealed priority areas for intervention. They also provide standard references to compare drug use situations and their change over time in different settings, area and time in Ethiopia.

Reducing perinatal mortality in developing countries

The perinatal mortality rate (PNMR) is a key health status indicator. It is multifactorial in aetiology and is significantly influenced by the quality of health care. While there is an ethical imperative to act to improve quality of care when deficiencies are apparent, the lack of controls--when an interventions is applied to an entire service--makes it difficult to infer a causal relationship between the intervention and any subsequent change in PNMR. However, by specifically measuring avoidable perinatal deaths (those due to error or omission on the part of the health service), this limitation is partially overcome, and the impact of the intervention can be more rigorously evaluated. This paper reports the impact of perinatal audit in a rural African health district between 1991 and 1995. A total of 21,112 consecutive births were studied: the average number of deliveries increased by 31% from 325 to 424 per month. The PNMR (birth weight > or = 1000g) in 1991 was 27/1000, increased to 42/1000 in 1992, and fell steadily to 26/1000 in 1995 (40% reduction; p = 0.002). The proportion of avoidable deaths fell from 19% in 1991 to zero in the second half of 1995 (p = 0.0008). While factors associated with perinatal mortality are many, complex, and interrelated, this report suggests that mortality can be reduced significantly in resource-poor settings by improving quality of health care. Including the measurement of avoidable deaths in perinatal audit allows the impact of interventions to be more rigorously assessed than by simple measuring the PNMR.

The impact of primary health care services on under-five mortality in rural Niger

BACKGROUND

Despite large investments in basic primary health care in sub-Saharan Africa over the past two decades, quantifying the contribution of national programme efforts to the reduction of infant/child mortality in the region has proven difficult. This study takes advantage of the phased implementation of the national Rural Health Improvement Program in Niger and conveniently timed survey data to reassess programme impact on under-five mortality during the 1980-1985 period.

METHODS

Health service use and under-five mortality rates for children born in the 5 years prior to the 1985 survey are compared for three groups of villages: villages served by a dispensary, villages served by village health teams (VHT), and villages without access to modern primary care services. Multi-level regression analyses using both household- and community-level variables are undertaken in estimating the magnitude of effects.

RESULTS

Children residing in villages proximate to health dispensaries were approximately 32% less likely to have died during the study period than children without access to modern health services. Village health teams were not, however, associated with significantly lower mortality probabilities. Formal test for endogeneity indicated that these effects were not the result of non-uniform/non-random allocation of resources.

CONCLUSIONS

The findings are largely supportive of the key premise underlying selective primary health care interventions - that packages of basic services can be effectively mounted nationally in poor countries and have a significant impact over a short time period. In Niger, less than optimal implementation of VHT appears to have reduced the magnitude of the impact achieved.

AIDS in Africa: what drugs do the carers want or need?

Our objectives were: (1) to discover requirements for treatment of patients with AIDS (PWAs) for health-care workers in eight English-speaking African countries; (2) to establish policies for supply of drugs, and develop a method for determining the contents of parcels (PWA-BOXes) for the relief of PWAs. Fifty-seven questionnaires were sent to non-government medical units treating PWAs, supplied by the charity Inter Care. Of these 37 units replied, two had no known PWAs, three were swamped by refugees; therefore, the total number analysed was 32. Only 24 units had access to HIV testing and the mean number of PWAs per unit was 58. The reported complications of AIDS were: diarrhoea 28 units; tuberculosis 27 units; pneumonia 28 units; sexually transmitted diseases 26; candidiasis 28 units; and herpes zoster 20. Lists of drug requirements were received. We present a protocol for calculation of contents of PWA-BOXes in the hope that this will provide guidelines for other workers in this field.

Maternity waiting shelters and pregnancy outcome: experience from a rural area in Zimbabwe

Despite efforts to improve prenatal and perinatal health care in developing countries, child-birth remains hazardous for both mother and child. Several measures have been initiated to try to improve maternal and perinatal morbidity and mortality. One such measure is the establishment of maternity waiting shelters at hospitals where mothers can wait so that, when they go into labour or develop antenatal complications, they can transfer to the hospital wards for management and safe delivery. From May 1987 to April 1989, we evaluated pregnancy outcome among 280 women using such a shelter in a remote rural district in Zimbabwe. Perinatal mortality was higher (29.8 per 1000) among 773 non-waiting mothers than among the waiting mothers (25.0 per 1000), although this was not statistically significant (p > 0.05). However, there were significantly more low birthweight babies (11.4%) among the non-waiting mothers than among the waiting mothers (4.3%) (p < 0.01). Fetal deaths were more common than early neonatal deaths, suggesting that maternal factors accounted for most of the perinatal deaths. Poor pregnancy outcome was associated more with primigravidae and grand multigravidae than with those who had had one to four pregnancies. We conclude that maternity waiting shelters can contribute to preventing low birthweight and, to a lesser extent, improve perinatal outcome. There is a need to strengthen health care referral systems and to increase efforts to improve other determinants of perinatal and maternal morbidity and mortality.

An evaluation of clinical indicators for severe paediatric illness

To help reduce paediatric morbidity and mortality in the developing world, WHO has developed a diagnostic and treatment algorithm that targets the principal causes of death in children, which include acute respiratory infection, malaria, measles, diarrhoeal disease, and malnutrition. With this algorithm, known as the Sick Child Charts, severely ill children are rapidly identified, through the presence of any one of 13 signs indicative of severe illness, and referred for more intensive health care. These signs are the inability to drink, abnormal mental status (abnormally sleepy), convulsions, wasting, oedema, chest wall retraction, stridor, abnormal skin turgor, repeated vomiting, stiff neck, tender swelling behind the ear, pallor of the conjunctiva, and corneal ulceration. The usefulness of these signs, both in current clinical practice and within the optimized context of the Sick Child Chart algorithm in a rural district of western Kenya, was evaluated. We found that 27% of children seen in outpatient clinics had one or more of these signs and that pallor and chest wall retraction were the signs most likely to be associated with hospital admission (odds ratio (OR) = 8.6 and 5.3, respectively). Presentation with any of these signs led to a 3.2 times increased likelihood of admission, although 54% of hospitalized children had no such signs and 21% of children sent home from the outpatient clinic had at least one sign. Among inpatients, 58% of all children and 89% of children who died had been admitted with a sign. Abnormal mental status was the sign most highly associated with death (OR = 59.6), followed by poor skin turgor (OR = 5.6), pallor (OR = 4.3), repeated vomiting (OR = 3.6), chest wall retraction (OR = 2.7), and oedema (OR = 2.4). Overall, the mortality risk associated with having at least one sign was 6.5 times higher than that for children without any sign. While these signs are useful in identifying a subset of children at high risk of death, their validation in other settings is needed. The training and supervision of health workers to identify severely ill children should continue to be given high priority because of the benefits, such as reduction of childhood mortality.

Controlling schistosomiasis: the cost-effectiveness of alternative delivery strategies

Sustainable schistosomiasis control cannot be based on large-scale vertical treatment strategies in most endemic countries, yet little is known about the costs and effectiveness of more affordable options. This paper presents calculations of the cost-effectiveness of two forms of chemotherapy targeted at school-children and compares them with chemotherapy integrated into the routine activities of the primary health care system. The focus is on Schistosoma haematobium. Economic and epidemiological data are taken from the Kilombero District of Tanzania. The paper also develops a framework for possible use by programme managers to evaluate similar options in different epidemiological settings. The results suggest that all three options are more affordable and sustainable than the vertical strategies for which cost data are available in the literature. Passive testing and treatment through primary health facilities proved the most effective and cost-effective option given the screening and compliance rates observed in the Kilombero District.

An evaluation of the quantity of antenatal care at rural health centres in Matebeleland North Province

The study was conducted to evaluate the quality of antenatal care (ANC) provided at rural health centres (RHC). Matebeleland North Province in Zimbabwe was selected as the study area. A qualitative, descriptive study was conducted with the application of the modified EPI/Cluster Sampling Method for the 30 rural health centres selected as primary sampling units. The research methodology consisted of an assessment of structure and process evaluation. Antenatal care clients attending rural health centres were interviewed, records audited and process observations undertaken of health centre staff performing antenatal duties. An inventory and use of equipment at these facilities was conducted. The study indicated that there was overall consumer satisfaction with the antenatal care services in the province. More than 65 pc of the clients indicating that they were less than 10 km from a health facility that provided antenatal care. As expected from the facility sample of women cost recovery did not feature as a barrier to assess. The professional performance by health workers at rural health centre level in the province in the provision of antenatal care was found to be unsatisfactory. Limited availability of equipment coupled with poor know-how contributed significantly to the provision of poor services. Whereas health workers were able to identify some pregnancy related risk factors, inadequate efforts were put into minimizing their contribution to the adverse outcome of pregnancy. The study proposes strategies to improve the quality of antenatal care through organisational review and implementation of relevant policies and technical procedures.

High-compliance tuberculosis treatment programme in a rural community

The global tuberculosis epidemic is being fuelled by dual infection with human immunodeficiency virus type I. Short-course chemotherapy is effective but usually fails for operational reasons. A community-based treatment programme of twice-weekly fully-supervised treatment is described in which 89% of surviving patients completed treatment under programme conditions. Half the patients were successfully supervised by non-health workers. New approaches are needed to combat the global tuberculosis epidemic.

Field tests for rational drug use in twelve developing countries

Increasing efforts are being made to improve drug-use practices and prescribing behaviour in developing countries. An essential tool for such work is an objective and standard method of assessment. We present here a set of drug-use indicators produced and tested in twelve developing countries. We describe practical applications, which include the use of indicators to increase awareness among prescribers in Malawi and Bangladesh, to identify priorities for action (eg, polypharmacy in Indonesia and Nigeria, overuse of injections in Uganda, Sudan, and Nigeria, and low percentage of patients who understood the dosage schedule in Malawi), and to quantify the impact of interventions in Yemen, Uganda, Sudan, and Zimbabwe.

Effects of new service charges on attendance at rural health facilities in Kenya

Kenyans have long enjoyed free outpatient health care at government facilities while paying for admission and for child delivery. In December 1989 user charges were introduced also for out-patient care at hospitals and health centres. This before-and-after study of one rural hospital, two health centres and two dispensaries in rural Kenya shows major and statistically significant early drops in outpatient attendance at the hospital (28%) and at the health centres (50 and 43%) followed by a slow increase during the following months. There was a modest, not significant, decline also at the dispensaries (14 and 7%) and in demand for services unaffected by the new fees and charges.

Levels and causes of maternal mortality in southern India

Most studies of maternal mortality are hospital based. However, in developing countries, where many such deaths take place in the home, hospital statistics do not reflect the true extent of maternal mortality. Furthermore, the socioeconomic and demographic factors and health behavior affecting maternal mortality are rarely known. A study conducted in 1986 in South India demonstrates a new approach to investigating maternal mortality that combines the collection of information from hospital and health-facility records, field surveys, and case-control studies. The findings from this study indicate that there were 7.98 maternal deaths per 1,000 live births. Approximately one-half of the deaths occurred in the home or on the way to the hospital. Maternal deaths accounted for 36 percent of mortality for women of reproductive age. Analysis reveals that many of these deaths were preventable and that significant differentials existed with regard to demographic, social, and behavioral factors between the cases of maternal deaths and the controls.

Changes in material resource levels in Jamaica's primary health care services between 1984 and 1991/1992

Jamaica's primary health-care services have been in a process of development since the 1970s. In 1984, a large management study collected data on levels of material resources (basic facilities, utilities, furniture, equipment and supplies items). Since 1984, serious staff shortages have affected the services, and there have been economic constraints, as well as a major hurricane. In order to measure changes over subsequent years, data on material resources were again collected in 1991/1992, using the same sample of 65 types 2 and 3 health centres as in 1984. Data were collected by interview with health centre staff. Results, whilst showing various changes item-by-item, showed constancy or minor improvements overall in levels of resources. Type 2 health centres continued to have lower resource levels than type 3s, even though the methodology allowed for their different needs where appropriate. Staff members' opinions of condition and adequacy of resources had become more positive than before. It was concluded that, in terms of material resources, activities within the primary health-care sector have offset the adverse effects of the macro-environmental conditions affecting the health centres. This method of material resource monitoring has implications for quality assessment of health facilities in primary health-care.

The cost of the district hospital: a case study in Malawi

Described in an analysis of the cost to the Ministry of Health of providing district health services in Malawi, with particular emphasis on the district hospital. District resource allocation patterns were assessed by carefully disaggregating district costs by level of care and hospital department. A strikingly low proportion of district recurrent costs was absorbed by salaries and wages (27-39%, depending on the district) and a surprisingly high proportion by medical supplies (24-37%). The most expensive cost centre in the hospital was the pharmacy. A total of 27-39% of total recurrent costs were spent outside the hospital and 61-73% on hospital services. The secondary care services absorbed 40-58% of district recurrent costs. Unit costs by hospital department varied considerably by district, with one hospital being consistently the most expensive and another the cheapest. A total of 3-10 new outpatients could be treated for the average cost of 1 inpatient-day, while 34-55 could be treated for the average cost of 1 inpatient. The efficiency of hospital operations, the scope for redistributing resources districtwide, and the costing methodology are discussed.

Indian experience of home based mothers card: ICMR task force study

To improve the quality of MCH services, a Home Based Mothers Card (HBMC) prepared and recommended by World Health Organization was adapted to Indian situation, and introduced in 1.5 lakh population of rural area covered by 6 participating centres under the aegis of Indian Council of Medical Research. Two thousand four hundred and forty six mothers were given this card and were followed up for a period of 2 years. Only 89.2 percent retrieval of the cards was possible after a period of 18 months. Screening of the population for "at risk" women monitoring and referral could be undertaken with the help of this card. Improved antenatal, and referral services were observed during the study period. The card (HBMC) was acceptable to the mothers as well as to the health workers, as a tool for improving the quality and coverage of MCH services being rendered at the Primary Health Centre.

Cost analysis in health planning and management in Papua New Guinea

In 1988 a study of the costs of rural health services was carried out in Papua New Guinea. The study collected data from a 16% sample of all health centers and subcenters and was able to determine average staffing patterns, total and average costs, and service levels for different types of facilities. The study methodology and findings have been found to have broad application for both planning and management of health services. The applications of cost analysis for planning and management of health services are discussed, and key recommendations are outlined for improving the efficiency and productivity of rural health facilities in Papua New Guinea.

Primary health care and immunisation in Iran

The Primary Health Care (PHC) network of Iran consists of a rural and an urban branch. While the rural branch presently covers a sizeable portion of the rural population, the urban PHC project is in its early stages of implementation. The Expanded Programme on Immunisation (EPI) in Iran, which started as an independent and vertical project in early 1983, is being gradually integrated into the PHC network as the latter expands. Results of the second PHC programme review of Iran shows that immunisation coverage of children has improved appreciably since the first PHC review, especially for BCG which stands at 56.3%. Complete immunisation at first birthday in the rural areas with the PHC services is 44.1%, whereas for urban areas other than Teheran it is 28.1%. While the high coverage in the rural areas is attributed to the 'active' approach and vigilance of the providers of immunisation (i.e. the community health workers and the vaccinators of the mobile teams), the higher coverage in the capital city of Teheran is attributed to the involvement of private paediatricians and the generally higher social, economic, and educational status as well as higher interest of mothers. It is noticed that the results of cluster sampling for determination of immunisation coverage in large metropolitan areas of the developing world must be interpreted with much care. The reason is that in these areas extreme fluctuations in the crude birth rate are common and therefore results tend to over-represent the attributes of the segment of population with lower birth rate. It is also argued that complete immunisation might not be the best indicator for assessing the progress of the immunisation efforts. These and other findings are discussed in detail. are discussed in detail.

Integration of mother and child health services in Ethiopia

In Wollo region of Ethiopia, various non-governmental officers have been working closely with each other and with the Regional Health Department to implement the policy of daily integrated mother and child health services. The record cards, registers, procedures and training courses of the separate 'vertically' organized services were brought together to enable the development of a model integrated service. There were improvements in accessibility, acceptability and output of the services. The system was evaluated by a joint Ministry of Health and UNICEF team, and was adopted for use in the rest of Ethiopia.