How do rural households perceive and prioritise malaria and mosquito nets? A study in five communities of Nigeria

The aim of this study was to determine households' levels of prioritization and perception of malaria, ordinary mosquito nets and insecticide-treated nets (ITNs). A cross-sectional survey was conducted in five malaria holo-endemic communities in Enugu State, South-eastern Nigeria. The household heads or the representatives from randomly selected households were interviewed, using a pre-tested interviewer-administered questionnaire. The majority of the respondents had a good knowledge about malaria and the use of ordinary mosquito nets to prevent malaria. However, few knew about the existence of ITNs. Most respondents also stated that malaria was a priority problem and perceived some risk of contracting it. Despite the high level of knowledge about the use of mosquito nets, only 14.0%, 15.7%, 9.6% and 8.0% of the respondents from four of the communities had ever purchased any type of mosquito nets, except in Orba where the proportion was 50.3%. However, more than 80% in all the communities expressed a desire to buy insecticide-treated mosquito nets for the prevention of mosquito bites. There was considerable knowledge about malaria and the use of mosquito nets to prevent it. There were also high levels of prioritization of the disease, mosquito nets and ITNs which signalled the possibility of establishing sustainable community-based ITN programmes, especially as households wanted to buy the ITNs.     

How do patients and health professionals perceive the role of family members in the decision-making process regarding the choice of a dialysis method? A qualitative study

BackgroundTherapeutic decisions often seem to be the product of interaction between health professionals and patients alone. However, some realities make it essential to consider family members when examining care of patients, especially in the construction of therapeutic choices. Implementation of measures such as therapeutic patient education to make the patient an actor in his own healthcare, and the impact of disease on the patient's social and professional activities mean there is an important place for family members in a patient's care pathway. This study aims to examine the role of family members and the family environment in decision-making on treatment for patients with chronic kidney disease. It also analyzes how they contribute to the construction of patients’ choices on dialysis methods through their involvement in a therapeutic patient education program.MethodsThis study involved thirty-six semi-structured interviews: sixteen with patients and twenty with health professionals. Therapeutic patient education sessions, interactions and information exchanges between patients and health professionals, as well as participant behaviours, were also observed. Analysis was thematic.ResultsResults indicate that the factors influencing the patient's choice of dialysis methods include the family environment as the place where the disease is experienced, the need to maintain family ties, the advice provided by family members and their active participation in therapeutic patient education sessions and partnership between family members and health professionals in the decision-making process.ConclusionThis study highlights the reality of decision-making processes that can start from a non-hospital setting. Furthermore, it argues for greater consideration of the needs, values, and preferences of family members in mechanisms designed to promote patient participation in therapeutic decisions.     

How do pediatricians vaccinate in Munich? A health care epidemiological study

Zusammenfassung Fragestellung: In welchem Umfang impfen die Kinderärzte in München und wodurch wird ihr Impfverhalten beeinflusst?Methoden: Schriftliche Befragung aller 133 im Jahr 1998 in München niedergelassenen Kinderärzte mit einem standardisierten Fragebogen.Ergebnisse: 97 Fragebögen konnten ausgewertet werden (73%). Die Hälfte der Münchner Kinderärzte führte in ausreichendem Umfang alle von der Ständigen Impfkommission am Robert-Koch-Institut (STIKO) empfohlenen Impfungen durch. Allein gegen Diphtherie, Tetanus und Poliomyelitis wurde in ausreichendem Umfang geimpft. Niedrig waren die Impfquoten bei Masern, Mumps und Röteln. Wichtigster Bestimmungsfaktor für die Impfquote war der Anteil der Eltern, der nach eingehender Aufklärung Impfungen gemäss den Empfehlungen der STIKO befürwortet. Von den Ärzten vermutete oder überbewertete Kontraindikationen waren ein weiterer Grund für unzureichenden Impfquoten.Schlussfolgerungen: Das gesundheitspolitische Ziel einer Eliminierung der Masern in Deutschland ist mit dem berichteten Impfverhalten nicht erreichbar. Um den Durchimpfungsgrad zu erhöhen, sollten die Empfehlungen der STIKO einen stärkeren Grad an Verbindlichkeit erhalten. Neben der Verpflichtung für Ärzte regelmässige, zertifizierte Impffortbildungen zu besuchen, sollte die Eigenverantwortung der Versicherten bzw. ihrer Eltern z.B. durch finanzielle Anreize in den Krankenkassenbeiträgen gefördert werden.

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Summary Objectives: The goal was to determine vaccination rates and predictors of vaccination behaviour of pediatricians in Munich, Germany.Methods: Standardised questionnaires were sent to all 133 office-based pediatricians in Munich.Results: 97 questionnaires (73%) were returned completely. Vaccination rates were sufficiently against diphtheria, tetanus, and poliomyelitis only. The other vaccinations recommended by the national immunisation advisory board (STIKO) were carried out to an insufficient extent. Vaccination rates of measles, mumps, and rubella were low. Parents' informed consent to STIKO's recommendations was the main determining factor of vaccination rates. Physicians' uncertainty in assessing contra-indications correctly was another important reason for insufficient vaccination rates.Conclusions: The health target of eliminating measles will not likely be reached. STIKO's recommendations as well as periodically vocational training courses, should be more compulsory to physicians. Self-responsibility of patients and parents should be raised by financial incentives on sick funds premiums.

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Résumé Objectifs: Déterminer le degré de vaccination pratiqué par les pédiatres munichois et les facteurs influençant le comportement vaccinal.Méthodes: Recueil de données écrites auprès des 133 pédiatres installés à Munich en 1998 à l'aide d'un questionnaire standardisé.Résultats: 97 formulaires ont pu être analysés (73%). La moitié des pédiatres munichois éffectuaient à un taux suffisant la totalité des vaccinations recommendées par la STIKO (Ständige Impfkomission am Robert Koch Institut = comission permanente pour la vaccination de l'Institut Robert Koch). La vaccination était pratiquée à un niveau suffisant uniquement pour la diphtérie, le tétanos et la polyomyélite. Les taux vaccinaux pour la rougeole, les oreillons et la rubéole étaient bas. Le principal facteur influençant le taux de vaccination est la proportion de parents partisans des vaccinations recommendées par la STIKO après avoir été conseillés de façon appropriée. Par ailleurs, l'interprétation abusive ou éxagérée des contrindications par les praticiens explique aussi le taux insuffisant de vaccination.Conclusions: Le but de la politique sanitaire d'éliminer la rougeole en Allemagne ne peut pas être atteint au vu du comportement vaccinal rapporté dans cette enquête. Pour améliorer le taux de vaccination, il serait souhaitable que les recommendations de la STIKO aient un caractère plus coercitif. Il faudrait établir une obligation pour les praticiens d'assister régulièrement à des conférences de formation certifiées et stimuler la responsabilisation des assurés sociaux (ou de leurs parents) par le biais d'avantages tarifaires.

     

Why do local authorities undertake controlled evaluations of health impact? A qualitative case study of interventions in housing

ObjectivesA significant amount of literature documents the challenges of undertaking evaluative research on the public health impacts of interventions in the non-health sector. However, few studies have investigated why such studies are undertaken despite the undoubted challenges. Taking housing as a case study, the authors aimed to identify the factors contributing to successful evaluative research in the non-health sector.Study designQualitative interview study.MethodsSemi-structured interviews with 16 investigators involved in seven successful experimental studies of housing interventions across the UK, analysed using thematic content analysis.ResultsIntervention studies were undertaken when existing collaborative links enabled ‘windows of opportunity’ to be exploited. Although different ‘cultures of evidence’ were reported across the collaborating teams, these did not necessarily map onto the public health research/non-academic divide, and did not undermine collaborative work when all parties could gain from taking part in the research.ConclusionsFocussing on success, rather than failure, suggests that to encourage the uptake of evaluative evidence in the non-health sector, efforts might be better directed at fostering opportunities for partnership building rather than simply on educating non-health partners in the principles of academic research.     

Government helper and citizen advocate? A case study of the multiple roles and pressures facing a nongovernmental organization contracted by government to strengthen community health in northern India

While nongovernmental organizations (NGOs) can potentially strengthen valuable citizen political engagement, NGOs that are increasingly oriented towards donor and government contracts may instead contribute to depoliticizing development. Amidst competing pressures, NGO experiences and agency in managing multiple roles require examination. We present a qualitative case study of an NGO implementing a government‐designed intervention to strengthen Village Health, Sanitation, and Nutrition Committees (VHSNCs) in rural north India. Despite a challenging context of community scepticism and poor government services, the NGO did successfully form VHSNCs by harnessing its respected interlocutor status, preexisting relationships, and ability to “sell” the VHSNC as a mechanism for improving local well‐being. While the VHSNC enabled community members to voice concerns to government officials, improvements often failed to meet community expectations. NGO staff endured community frustration on one hand and rebuffs from lower‐level officials on the other, while feeling undersupported by the government contract. Consequently, although contracted to strengthen a community institution, the NGO increasingly worked alongside VHSNC members to try to strengthen the public sector. Contrary to assumptions that NGOs become “tamed” through taking government contracts, being contracted to deliver inputs for community participation was intertwined with microlevel political action, though this came at a cost to the NGO.     

How do residents of aged care homes perceive physical activity and functional independence? A qualitative study

Limited evidence exists concerning knowledge and understanding of how to optimally support residents’ physical activity, mobility and functional independence in residential aged care homes. An interpretive qualitative study was conducted to explore residents’ perceptions and experiences of opportunities for physical activity and functional independence, and how physical activity and functional independence are challenged in their care home environment. Purposefully sampled 24 participants (male = 13) from five not‐for‐profit residential aged care homes in the outskirts of a metropolitan area in Australia, were interviewed between August and September 2017. Maintaining independence was found to be the utmost priority for nearly all participants in this study. Yet, many did not make the connection between physical activity and independence, and regarded ‘exercise’ as an inappropriate activity for them, perceiving it as high‐impact, high‐intensity activity in commercial gyms that was only appropriate for the young. Walking and gardening were found to be most popular. Walking could be a physical activity, social activity, solo recreational activity and a means of maintaining mobility and functional independence—all of which residents considered to be appropriate to them and achievable. The study identified key factors influencing physical activity and functional independence of residents: levels of activity prior to living in residential aged care, ageism, social capital and loss of a loved one, pain and staff support. Findings highlight the need for a ‘flexible and inclusive’ approach in facilitating the resident's physical activity, and a greater role for staff in encouraging residents’ engagement in, and communicating the benefits and requirements of, physical activity, through, for example, motivational interviewing.     

How well do members of the public deal with a distributive justice problem in health care?

OBJECTIVES: There is some debate about the appropriateness of involving the general public in decisions concerning the prioritising and rationing of health care resources. Doubt has been expressed about the public's ability to deal with these issues in a fair and rational way without taking refuge in ready-made official ideologies. This study considers the quality of discussion achieved by members of the public on this issue in terms of their ability to recognise the validity of conflicting arguments, to cope with the shifting positions created by these conflicts, and to avoid opting for simplistic ready-made solutions. It also records the participants' own perceptions of the quality of their discussion. METHODS: Four focus groups were recruited through community organisations in a suburban area of Derby, and were asked to evaluate criteria for the rationing of donor livers for transplantation, relating this to specific patient profiles. Discussions were recorded, transcribed and analysed using qualitative methods. RESULTS: Three groups showed an ability to work with shifting and conflicting arguments on most issues they discussed, but two of these groups showed a tendency to adopt simplistic solutions on one specific issue. The fourth group adopted a clear-cut solution to the main issues early on, and adhered to it for the rest of the discussion. CONCLUSION: The overall performance of the groups suggests that rational and open public discussion can be achieved, but that participants may need support in avoiding premature adoption of simplistic solutions.     

Does social participation improve self-rated health in the older population? A quasi-experimental intervention study

Social participation has been linked to healthy aging and the maintenance of functional independence in older individuals. However, causality remains tenuous because of the strong possibility of reverse causation (healthy individuals selectively participate in social activities). We describe a quasi-experimental intervention in one municipality of Japan designed to boost social participation as a way of preventing long-term disability in senior citizens through the creation of ‘salons’ (or community centers). In this quasi-experimental intervention study, we compared 158 participants with 1391 non-participants in salon programs, and examined the effect of participation in the salon programs on self-rated health. We conducted surveys of community residents both before (in 2006) and after (in 2008) the opening of the salons. Even with a pre/post survey design, our study could be subject to reverse causation and confounding bias. We therefore utilized an instrumental variable estimation strategy, using the inverse of the distance between each resident's dwelling and the nearest salon as the instrument. After controlling for self-rated health, age, sex, equivalized income in 2006, and reverse causation, we observed significant correlations between participation in the salon programs and self-rated health in 2008. Our analyses suggest that participation in the newly-opened community salon was associated with a significant improvement in self-rated health over time. The odds ratio of participation in the salon programs for reporting excellent or good self-rated health in 2008 was 2.52 (95% CI 2.27–2.79). Our study provides novel empirical support for the notion that investing in community infrastructure to boost the social participation of communities may help promote healthy aging.     

How do people with learning disability experience the city centre? A Sheffield case study

The use of city centre spaces by people with learning disability is not much debated in the literature. Here we include the thoughts and opinions of groups of people with learning disability as we undertook some guided walks through Sheffield city centre.We found that few of the participants had independent access to the city centre. Many cited concerns over personal safety and the most, on few occasions when they did visit, did so with family and/or paid staff for pre-planned purposes, usually linked to shopping. The need for appropriate support figured prominently. There is also a need to re-assess what we mean by social inclusion for this cohort.     

How do patients come to be seen as ‘difficult’?: A mixed-methods study in community mental health care

Across all health care settings, certain patients are perceived as 'difficult' by clinicians. This paper's aim is to understand how certain patients come to be perceived and labelled as 'difficult' patients in community mental health care, through mixed-methods research in The Netherlands between June 2006 and October 2009. A literature review, a Delphi-study among experts, a survey study among professionals, a Grounded Theory interview study among 'difficult' patients, and three case studies of 'difficult' patients were undertaken. Analysis of the results of these qualitative and quantitative studies took place within the concept of the sick role, and resulted in the construction of a tentative explanatory model. The 'difficult' patient-label is associated with professional pessimism, passive treatment and possible discharge or referral out of care. The label is given by professionals when certain patient characteristics are present and a specific causal attribution (psychological, social or moral versus neurobiological) about the patient's behaviours is made. The status of 'difficult' patient is easily reinforced by subsequent patient and professional behaviour, turning initial unusual help-seeking behaviour into 'difficult' or ineffective chronic illness behaviour, and ineffective professional behaviour. These findings illustrate that the course of mental illness, or at least the course of patients' contact with mental health professionals and services, is determined by patient and professional and reinforced by the social and mental health care system. This model adds to the broader sick role concept a micro-perspective in which attribution and learning principles are incorporated. On a practical level, it implies that professionals need to look into their own role in the perpetuation of difficult behaviours as described here.     

How do you measure trust in the health system? A systematic review of the literature

People's trust in the health system plays a role in explaining one's access to and utilization of medical care, adherence to medications, continuity of care, and even self-reported health status. Yet it is not easy to find trust measures and understand what they are measuring. A systematic review of scales and indices identified 45 measures of trust within the health system with an average of 12 questions each, which quantified levels of trust among various relationships across the health system. Existing evidence was narrow in scope, where half examined the relationship between doctors/nurses and patients, and the majority were designed, tested and validated in the United States. We developed a health systems trust content area framework, where we identified that honesty, communication, confidence and competence were captured frequently in these measures, with less focus on concepts such as fidelity, system trust, confidentiality and fairness. Half of the measures employed a qualitative method in the design of these measures and 33% were pilot tested. Reporting of test–retest reliability and inter-rater reliability were less common. This review identifies a need to develop measurements of trust beyond doctor–patient relationships and outside of U.S. contexts, and strengthen the rigor of existing trust measures. Greater development and use of trust measures in the health system could improve monitoring and evaluation efforts, which may in turn result in better health outcomes.     

How much do workers’ health examinations add to health and safety at the workplace? Occupational preventive usefulness of routine health examinations

ObjectiveDespite no evidence in favour, routine workers’ health examinations, mostly pre-employment and periodic, are extensively performed worldwide with important allocation of resources. In Spain they are performed within a theoretical job-specific health surveillance system. Our objective was to ascertain their occupational preventive usefulness from the perspective of occupational health professionals.MethodsCross sectional study. Online survey addressed to all physicians and nurses members of the Catalan Society of Safety and Occupational Medicine (n = 539) in 2011. Univariate and bivariate analyses of prevalence and prevalence differences of answers.ResultsResponse rate 53% (n = 285). According to more than 70% of respondents the health surveillance system isn’t cost-effective, doesn’t meet the goal of early detection of health damage related to work, and doesn’t contribute to improve the occupational risk prevention system. Further deficiencies were identified regarding specificity and scientific basis for health examinations, quality of collective health surveillance and referral of suspected cases to mutual insurance companies for diagnosis and treatment. Bivariate analysis showed a significantly more negative opinion for several items amongst physicians (versus nurses) and amongst professionals working in external prevention services (versus internal services).ConclusionsThis study raises serious concerns about how health examinations are performed within our workers’ health surveillance system, which should be reviewed to ensure the fulfilment of its occupational preventive objective. Our results might encourage other countries with similar practices to assess them in order to assure their fitness for purpose.     

How do persons with dementia participate in decision making related to health and daily care? A multi-case study

ABSTRACT: BACKGROUND: Many countries have passed laws giving patients the right to participate in decisions about health care. People with dementia cannot be assumed to be incapable of making decisions on their diagnosis alone as they may have retained cognitive abilities. The purpose of this study was to gain a better understanding of how persons with dementia participated in making decisions about health care and how their family carers and professional caregivers influenced decision making. METHODS: This Norwegian study had a qualitative multi-case design. The triad in each of the ten cases consisted of the person with dementia, the family carer and the professional caregiver, in all 30 participants. Inclusion criteria for the persons with dementia were: (1) 67 years or older (2) diagnosed with dementia (3) Clinical Dementia Rating score 2, moderate dementia; (3) able to communicate verbally. The family carers and professional caregivers were then asked to participate. A semi-structured interview guide was used in interviews with family carers and professional caregivers. Field notes were written after participant observation of interactions between persons with dementia and professional caregivers during morning care or activities at a day centre. How the professional caregivers facilitated decision making was the focus of the observations that varied in length from 30 to 90 minutes. The data were analyzed using framework analysis combined with a hermeneutical interpretive approach. RESULTS: Professional caregivers based their assessment of mental competence on experience and not on standardized tests. Persons with dementia demonstrated variability in how they participated in decision making. Pseudo-autonomous decision making and delegating decision making were new categories that emerged. Autonomous decision making did occur but shared decision making was the most typical pattern. Reduced mental capacity, lack of available choices or not being given the opportunity to participate led to non-involvement. Not all decisions were based on logic; personal values and relationships were also considered. CONCLUSIONS: Persons with moderate dementia demonstrated variability in how they participated in decision making. Optimal involvement was facilitated by positioning them as capable of influencing decisions, assessing decision-specific competence, clarifying values and understanding the significance of relationships and context.     

How do obese individuals perceive and respond to the different types of obesity stigma that they encounter in their daily lives? A qualitative study

Obesity stigma exists within many institutions and cultural settings. Most studies suggest that stigmatising experiences have a negative impact on individuals' health and social behaviours and outcomes. However, some studies indicate that obesity stigma can motivate individuals to lose weight. Limited research has examined weight-based stigma from the perspective of obese individuals, including their perceptions of, and responses to, the different types of weight-based stigma they face in their daily lives. This study advances knowledge about weight-based stigma by documenting how obese adults (mostly female) described the different types of obesity stigma that they faced, how they responded to this stigma, and how different types of stigma impact on health and social wellbeing. Semi-structured, qualitative interviews were conducted between April 2008 and March 2009 with a diverse sample of 141 obese Australian adults. Guided by Link and Phelan's (2006) categorisation of different types of discrimination, participants' experiences could be grouped into three distinct types of stigma: 1) Direct (e.g. being abused when using public transport); 2) Environmental (e.g. not being able to fit into seats on planes); and 3) Indirect (e.g. people staring at the contents of their supermarket trolley). Participants described that more subtle forms of stigma had the most impact on their health and social wellbeing. However, it was the interaction between direct, environmental and indirect stigma that created a barrier to participation in health-promoting activities. Participants rarely challenged stigma and often blamed themselves for stigmatising experiences. They also avoided situations where they perceived they would be stigmatised and constantly thought about how they could find a solution to their obesity.     

Does decentralization influence efficiency of health units? A study of opinion and perception of health workers in Odisha

Background

Health systems in low and middle income countries are struggling to improve efficiency in the functioning of health units of which workforce is one of the most critical building blocks. In India, Rogi Kalyan Samiti (RKS) was established at every health unit as institutions of local decision making in order to improve productive efficiency and quality. Measuring efficiency of health units is a complex task. This study aimed at assessing the perception (opinion and satisfaction) of health workers about influence of RKS on improving efficiency of peripheral decision making health units (DMHU); examining differences between priority and non-priority set-ups; identifying predictors of satisfaction at work; and discussing suggestions to improve performance.

Methods

Following a cross-sectional, comparative study design, 130 health workers from 30 institutions were selected through a multi-stage stratified random sampling. A semi-structured questionnaire was administered to assess perception and opinion of health workers about influence of RKS on efficiency of decision making at local level, motivation and performance of staff, and availability of funds; improvement of quality of services, and coordination among co-workers; and participation of community in local decision making. Three districts with highest infant mortality rate (IMR), one each, from 3 zones of Odisha and 3 with lowest IMR were selected on the basis of IMR estimates of 2011. The former constituted priority districts (PD) and the latter, non-priority districts (NPD). Composite scores were developed and compared between PD and NPD. Adjusted linear regression was conducted to identify predictors of satisfaction at work.

Results

A majority of respondents felt that RKS was efficient in decision making that resulted in improvement of all critical parameters of health service delivery, including quality; this was significantly higher in PD. Further, higher proportion of respondents from PD was highly satisfied with the current set of provisions and manners of functioning of the sample health units. Active community engagement, participation of elected representatives, selection of a pro-active Chairman, and training to RKS members were suggested as the immediate priority action points for the state government. Mean scores differed significantly between PD and NPD with regard to: influence of RKS on individual-centric, organizational-centric and patient-centric performance, and the responsibilities to be entrusted with RKS. Absenteeism was strongly associated with satisfaction and local self-governance. Work-related factors, systemic factors, local accountability and patients’ involvement were found to be the key predictors of satisfaction of health workforce.

Conclusion

The understanding on quality improvement strategies was found to be very poor among the health workers. Tailor-made capacity building measures at district and sub-district levels could be critical to equip the peripheral health units to achieve the universal health coverage goals. Work environment, systemic factors and accountability need to be addressed on priority for retention of health workforce. The hypothesized link between efficient local decision making, perception of health workers about efficiency of health units and the health status of population needs further investigation.