Decentralization and immunization program in a single-party state: the case of the Lao People's Democratic Republic

BACKGROUND

The Lao People's Democratic Republic (Lao PDR), a lower-middle-income country, lags behind other Southeast Asian countries in immunization coverage for children under two years of age. The organization of health services is a key determinant of the functionality of immunization programs. However, this aspect, and in particular its decentralization component of the healthcare system, has never been studied.

METHODS

A case study in the Lao National Immunization Program was performed using a neo-institutional theory-based conceptual framework, highlighting the structure (rules, laws, resources, etc.) and interpretative schemes (dominant beliefs and ideas) that underlie the state of decentralization of the healthcare system that support the conduct of the immunization program. Twenty-two semi-structured interviews were conducted with representative actors from various government levels, external donors, and civil society, in four provinces. Data were complemented with information retrieved from relevant documents.

RESULTS

The Lao healthcare system has a deconcentrated form of decentralization. It has a largely centralized structure, albeit with certain measures promoting the decentralization of its immunization programs. The structure underlying the state of centralization of immunization services provided is coherent with a shared dominant interpretive scheme. However, the rapid economic, technical, and educational changes affecting the country suggest that the coherence between structure and interpretative schemes is bound to change.

CONCLUSION

Unprecedented opportunities to access quality higher education and the use of social networks are factors in Lao PDR that could affect the distribution of responsibilities of the different levels of government for public health programs such as the National Immunization Program.

The Call for Neuroendoscopy Cadaveric Workshops in Lower-Middle Income Countries

OBJECTIVE

This study aims to assess the impact of the workshops organized during Neuroendocon 23 on the perspective and confidence of neurosurgeons toward endoscopy in a lower-middle income country.

METHODS

Neuroendocon 23 had cranial and spinal endoscopy cadaveric workshops with 30 delegates each. A pre and postworkshop survey was disseminated among the delegates, and statistical analysis was performed with SPSS (version 26) using P < 0.05.

RESULTS

A total of 24 delegates (40%) consented to participate in the study, with only 1 female respondent (4.17%). After the cranial endoscopy workshop, there was an increase in the level of confidence of delegates in cranial endoscopic approaches (P < 0.001). Similarly, after the spine endoscopy workshop, the respondents had increased confidence in managing spine conditions with the endoscopic approach (P = 0.040), to the extent that they preferred the endoscopic over the microsurgical technique (P < 0.001). All respondents (n = 24, 100%) believed that endoscopy should be promoted in lower-middle income countries and integrated into residency curricula.

CONCLUSIONS

Cranial and spinal endoscopy cadaveric workshops could be the first step in stimulating the interest of neurosurgeons in endoscopy.

Median to Radial Nerve Transfer: An 8-Year Experience From a Lower-Middle Income Country

INTRODUCTION

With an incidence of 2-16%, radial nerve palsy is one of the common forms of nerve injuries globally. Radial nerve palsy causes debilitating effects including loss of elbow extension, wrist drop and loss of finger extension. Reparative surgical pathways range from primary repair and neurolysis, to nerve grafting, nerve transfers, and tendon transfers. Due to ease of performance and acceptability and reproducibility of outcomes, tendon transfers are considered the gold standard of radial nerve palsy repair. However, independent finger function cannot be achieved and as such may not give truly desirable results. In lower-middle income countries, the question of nerve transfer versus tendon transfer for patients who are keen to get back to work is key. While tendon transfer recovery is faster, the functional loss is often considered devastating for fine hand function due to loss of grip secondary to lack of wrist and finger extension. In this study, we present our experience of performing median nerve transfers for radial nerve palsy in Pakistan.

METHODS

We performed a retrospective case-series of patients undergoing median to radial nerve transfer for radial nerve palsy over a period of 6 y, from 2012 to 2019. Patients with radial nerve palsy were diagnosed via electromyography and nerve conduction studies. The procedure involved coapting the branches of the flexor carpi radialis and flexor digitorum superficialis (long and ring finger) nerves to the posterior interosseous nerve and extensor carpi radialis brevis, respectively. Patients were assessed using the Medical Research Council scale for muscle strength of wrist, finger and thumb extension separately at 1 y time. Our results were then compared to results from similar nerve transfer studies.

RESULTS

We operated on 10 right-hand dominant patients, eight males and two females with a median age of 33 y (6-63 y). four sustained injury to the right hand and six to the left. Causes of the injuries included road traffic accident (n = 3), firearm injury (n = 4), shrapnel (n = 1), iatrogenic injury (injection in deltoid region (n = 1) and fall (n = 1). Types of fracture included mid humerus fracture, fracture of the surgical neck of the humerus, and supracondylar fracture of the humerus. Median time to surgery since injury was 4 mo (1-8 mo). Independent wrist extension was M4+ in all patients and independent finger extension was M4+ in seven and M4-in two patients. However, a patient who presented late at 8 mo had poorer finger outcomes with extension at M2-. All patients had independent movement of fingers.

CONCLUSIONS

Nerve transfer is a reliable method of post traumatic nerve repair and reinnervation, particularly in lower-middle income countries, even in cases where the nerve damage is severe and extensive and up to 6 mo may have elapsed between injury and presentation. Timely median to radial nerve transfer is a highly recommended option for radial nerve palsy, with regular follow-ups and physical therapy added to ensure positive outcomes.

Comparing presentations and outcomes of children with cancer: a study between a lower-middle-income country and a high-income country

BACKGROUND

Substantial progress has been achieved in managing childhood cancers in many high-income countries (HICs). In contrast, survival rates in lower-middle-income countries (LMICs) are less favorable. Here, we aimed to compare outcomes and associated factors between two large institutions; Egypt (LMIC) and Germany (HIC).

METHODS

A retrospective review was conducted on newly diagnosed children with cancer between 2006 and 2010 in the departments of pediatric oncology at the South Egypt Cancer Institute (SECI) (n = 502) and the University Hospital of Cologne-Uniklinik Köln (UKK) (n = 238). Characteristics including age, sex, diagnosis, travel time from home to the cancer center, the time interval from initial symptoms to the start of treatment, treatment-related complications, compliance, and outcome were analyzed. A Cox proportional hazards regression model was applied to investigate the influence of risk factors.

RESULTS

The most common diagnoses in SECI were leukemia (48.8%), lymphomas (24.1%), brain tumors (1%), and other solid tumors (24.7%), compared to 22.3%, 19.3%, 28.6%, and 26.5% in UKK, respectively. Patients from SECI were younger (5.2 vs. 9.0 years, P < 0.001), needed longer travel time to reach the treatment center (1.44 ± 0.07 vs. 0.53 ± 0.03 h, P < 0.001), received therapy earlier (7.53 ± 0.59 vs. 12.09 ± 1.01 days, P = 0.034), showed less compliance (85.1% vs. 97.1%, P < 0.001), and relapsed earlier (7 vs. 12 months, P = 0.008). Deaths in SECI were more frequent (47.4% vs. 18.1%) and caused mainly by infection (60% in SECI, 7% in UKK), while in UKK, they were primarily disease-related (79% in UKK, 27.7% in SECI). Differences in overall and event-free survival were observed for leukemias but not for non-Hodgkin lymphoma.

CONCLUSIONS

Outcome differences were associated with different causes of death and other less prominent factors.

Pathways to care: a case study of traffic injury in Vietnam

BACKGROUND

Traffic injuries place a significant burden on mortality, morbidity and health services worldwide. Qualitative factors are important determinants of health but they are often ignored in the study of injury and corresponding development of prehospital Emergency Medical Services (EMS), especially in developing country settings. Here we report our research on sociocultural factors shaping pathways to hospital care for those injured on the roads and streets of Vietnam.

METHODS

Qualitative fieldwork on pathways to emergency care of traffic injury was carried out from March to August 2016 in four hospitals in Vietnam, two in Ho Chi Minh City and two in Hanoi. Forty-eight traffic injured patients and their families were interviewed at length using a semi-structured topic guide regarding their journey to the hospital, help received, personal beliefs and other matters that they thought important. Transcribed interviews were analysed thematically guided by the three-delay model of emergency care.

RESULTS

Seeking care was the first delay and reflected concerns over money and possessions. The family was central for transporting and caring for the patient but their late arrival prolonged time spent at the scene. Reaching care was the second delay and detours to inappropriate primary care services had postponed the eventual trip to the hospital. Ambulance services were misunderstood and believed to be suboptimal, making taxis the preferred form of transport. Receiving care at the hospital was the third delay and both patients and families distrusted service quality. Request to transfer to other hospitals often created more conflict. Overall, sociocultural beliefs of groups of people were very influential.

CONCLUSIONS

Analysis using the three-delay model for road traffic injury in Vietnam has revealed important barriers to emergency care. Hospital care needs to improve to enhance patient experiences and trust. Socioculture affects each of the three delays and needs to inform thinking of future developments of the EMS system, especially for countries with limited resources.

Risk factors for postpartum sepsis: a nested case-control study

Background

The Majority (99%) of maternal deaths occur in low and middle-income countries. The three most important causes of maternal deaths in these regions are postpartum hemorrhage, pre-eclampsia and puerperal sepsis. There are several diagnostic criteria used to identify sepsis and one of the commonly used criteria is systematic inflammatory response syndrome (SIRS). However, these criteria require laboratory investigations that may not be feasible in resource-constrained settings. Therefore, this study aimed to develop a model based on risk factors and clinical signs and symptoms that can identify sepsis early among postpartum women.

Methods

A case-control study was nested in an ongoing cohort of 4000 postpartum women who delivered or were admitted to the study hospital. According to standard criteria of SIRS, 100 women with sepsis (cases) and 498 women without sepsis (controls) were recruited from January to July 2017. Information related to the socio-demographic status, antenatal care and use of tobacco were obtained via interview while pregnancy and delivery related information, comorbid and clinical sign and symptoms were retrieved from the ongoing cohort. Multivariable logistic regression was performed and discriminative performance of the model was assessed using area under the curve (AUC) of the receiver operating characteristic (ROC).

Results

Multivariable analysis revealed that 1–4 antenatal visits (95% CI 0.01–0.62).

, 3 or more vaginal examinations (95% CI 1.21–3.65), home delivery (95% CI 1.72–50.02), preterm delivery, diabetes in pregnancy (95% CI 1.93–20.23), lower abdominal pain (95% CI 1.15–3.42)) vaginal discharge (95% CI 2.97–20.21), SpO2 < 93% (95% CI 4.80–37.10) and blood glucose were significantly associated with sepsis. AUC was 0.84 (95% C.I 0.80–0.89) which indicated that risk factors and clinical sign and symptoms-based model has adequate ability to discriminate women with and without sepsis.

Conclusion

This study developed a non-invasive tool that can identify postpartum women with sepsis as accurately as SIRS criteria with good discriminative ability. Once validated, this tool has the potential to be scaled up for community use by frontline health care workers.

Pneumococcal carriage in vaccine-eligible children and unvaccinated infants in Lao PDR two years following the introduction of the 13-valent pneumococcal conjugate vaccine

Pneumococcal carriage is a prerequisite for disease, and underpins herd protection provided by pneumococcal conjugate vaccines (PCVs). There are few data on the impact of PCVs in lower income settings, particularly in Asia. In 2013, the Lao People's Democratic Republic (Lao PDR) introduced 13-valent PCV (PCV13) as a 3 + 0 schedule (doses at 6, 10 and 14 weeks of age) with limited catch-up vaccination. We conducted two cross-sectional carriage surveys (pre- and two years post-PCV) to assess the impact of PCV13 on nasopharyngeal pneumococcal carriage in 5-8 week old infants (n = 1000) and 12-23 month old children (n = 1010). Pneumococci were detected by quantitative real-time PCR, and molecular serotyping was performed using DNA microarray. Post PCV13, there was a 23% relative reduction in PCV13-type carriage in children aged 12-23 months (adjusted prevalence ratio [aPR] 0.77 [0.61-0.96]), and no significant change in non-PCV13 serotype carriage (aPR 1.11 [0.89-1.38]). In infants too young to be vaccinated, there was no significant change in carriage of PCV13 serotypes (aPR 0.74 [0.43-1.27]) or non-PCV13 serotypes (aPR 1.29 [0.85-1.96]), although trends were suggestive of indirect effects. Over 70% of pneumococcal-positive samples contained at least one antimicrobial resistance gene, which were more common in PCV13 serotypes (p < 0.001). In 12-23 month old children, pneumococcal density of both PCV13 serotypes and non-PCV13 serotypes was higher in PCV13-vaccinated compared with undervaccinated children (p = 0.004 and p < 0.001, respectively). This study provides evidence of PCV13 impact on carriage in a population without prior PCV7 utilisation, and provides important data from a lower-middle income setting in Asia. The reductions in PCV13 serotype carriage in vaccine-eligible children are likely to result in reductions in pneumococcal transmission and disease in Lao PDR.

The impact of multiple interventions to reduce household exposure to second-hand tobacco smoke among women: a cluster randomized controlled trial in Kalutara district, Sri Lanka

Background

Second-hand smoke (SHS) in households remains a serious public health problem in Sri Lanka, partly due to a lack of voluntary prohibitions of tobacco smoking inside houses. Women are especially at risk of being exposed. Effective community based interventions to reduce the SHS in households targeting women is scarce. The objective of this study was to examine the impact of a multi-component intervention on household SHS exposure among Sri Lankan women.

Methods

Thirty clusters of 25 women (aged 18–65) from 750 households were randomized into the intervention and control groups. Women in the intervention group were exposed to activities which focused on improving knowledge on the health effects of SHS, attitudes towards SHS exposure, right to a smoke-free living and women empowerment against smoking. The duration of the intervention was six months. The comparison group received no intervention. The primary outcome of interest was self-reported SHS exposure in the household within 7 days prior to data collection. The secondary outcomes were exposure in the past 30 days, knowledge of the health risks of exposure, attitudes towards exposure, right to smoke-free living, women empowerment against smoking, and smoking inside the homes.

Results

Final assessment was in 329 (89.6%) in the intervention group and 309 (85.8%) in the comparison group. Following the intervention, significantly lower proportion of women in the intervention group as compared to the control group reported SHS exposure in their households within 7-days (9.2% vs. 15.3%, p = 0.02) and 30-days (13.6% vs. 21.6%, p = 0.008) prior to the post survey. As compared to the control group, significantly higher median scores were observed in the intervention group on the knowledge of the health risks of exposure to SHS (p < 0.001), attitudes on exposure to SHS (p = 0.004), right to smoke free living (p = 0.001) and women empowerment (p < 0.001).

Conclusion

Multi-component intervention activities were effective in reducing household exposure to SHS among women.

Trial registration

Sri Lanka Clinical Trials Registry SLCTR/2014/033.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4820-8) contains supplementary material, which is available to authorized users.