Why do child contacts of multidrug-resistant tuberculosis not come to the assessment clinic?

Background:

Local policy advises that children exposed to multidrug-resistant tuberculosis (MDR-TB) should be assessed in a specialist clinic. Many children, however, are not brought for assessment.

Methods:

Focus group discussion was used to design appropriate questionnaires. From 1 September 2011, the first 50 children referred to the specialist paediatric MDR-TB clinic, Cape Town, South Africa, and who attended their clinic appointment, were recruited. The first 50 children who were referred but who did not attend were concurrently identified, traced and recruited. Differences in group characteristics were compared.

Results:

The median age of the children was 35 months: 48 (48%) were boys, 4 (4%) were human immunodeficiency virus infected and 47 (47%) were of coloured ethnicity. Factors significantly associated with non-attendance at the MDR-TB clinic were: Coloured ethnicity (OR 2.82, 95%CI 1.21–6.59, P = 0.01), the mother being the source case (OR 3.78, 95%CI 1.29–11.1, P = 0.02), having a smoker resident in the house (OR 2.37, 95%CI 1.01–5.57, P = 0.04), the time (P = 0.002) and cost (P = 0.03) required to get to the specialist clinic, and fear of infection whilst waiting to be seen (OR 2.45, 95%CI 1.07–5.60, P = 0.03).

Conclusions:

Reasons for non-attendance at paediatric MDR-TB clinic appointments are complex and are influenced by demographic, social, logistical and cultural factors.     

A new cardiothoracic centre: 'how to do it?'

All cardiac surgical patients, emergency and routine, from the South West peninsula of England had to travel long distances until 19 months ago, a stressful if not dangerous situation. This paper describes the planning, commissioning and start-up of a brand new cardiac surgical facility. The lessons learnt may help similar projects as provision of specialist health care decentralizes.     

How much do Nepalese mothers know about child development?

Parental knowledge on child development is important for maximal developmental potential. This study was conducted to assess mothers’ knowledge on child development in Nepal. The Caregivers Knowledge of Child Development Inventory (CKCDI) was used to interview mothers. Total of 1272 mothers were interviewed. Out of the total CKCDI score of 40, mean score (SD) obtained by mothers was 20 (4.8). Mothers’ knowledge on the developmental milestone composite was better than stimulation composite with scores of 11.14 (3.09) and 8.9 (3.17), respectively (p?<?.005). Few mothers (38%) identified the correct ages of developmental milestones. Although most of the mothers knew about teaching their children to count or name colors, few knew when to start to read with children. With low level of knowledge on child development among Nepalese mothers, early childhood development programmes should be considered integrated with other health care programmes targeting young children and families.     

Workforce literacy: do we have a choice?

Rapidly occurring demographic change and the demand for higher and higher skills in the workforce present a challenge for business and education. The investment the workplace makes in basic education for its employees will not only increase skills, but positively affect attitudes toward the employer, stimulate a desire for education and promotion and raise self-esteem. The rich mix of racial, ethnic and global experiences represented in today's workforce is a great potential advantage. We must face the question of best developing this potential for the future. Investment in personnel is not only worth-while--there is no other choice. We must not lose the opportunity.     

Mifepristone: where do we come from and where are we going? Clinical development over a quarter of a century

Administration of mifepristone followed by the prostaglandin, misoprostol, has been used successfully in the medical termination of pregnancy for over 25 years, and the method is registered in 35 countries. Single doses of mifepristone are also effective as an emergency postcoital contraceptive. Mifepristone administered for 3 months or longer to women with uterine leiomyomas, is associated with a reduction in pain and bleeding with improvement in quality of life and decrease in fibroid size. Mifepristone is also effective in decreasing pain in women with endometriosis. In both these conditions, serum estradiol levels are in the range of those in the early follicular phase. A daily dose of at least 2 mg mifepristone blocks ovulation. In contrast, weekly administration of 25 or 50 mg does not consistently block ovulation but has contraceptive potential by delaying endometrial development. Mifepristone in a dose of 200 mg, administered 48 h after the Luteinizing Hormone (LH) surge, also acts as a contraceptive, but this strategy is not practical for widespread use. Administration of mifepristone for 4-6 months or longer may lead to endometrial thickening. Endometrial histology reveals cystic glandular dilation together with admixed estrogen (mitotic) and progestin (secretory) epithelial effects. This histological pattern does not represent endometrial hyperplasia.     

Measuring inequalities in health: What do we know? What do we need to know?

We argue that policy analysis aiming at curving inequalities in health calls for a better understanding of what we know about its measurement pathways. Assuming that health is a good that individuals trade off against other goods, unavoidable health inequalities result when after controlling for unavoidable factors (e.g., age and gender), differences in socioeconomic status of an individual systemically engender differences in health outcomes. However, the measurement of such inequality and underpinning reasons behind are not suggestive of a clear picture. In reviewing the literature, we conclude that it is unclear what the evidence suggests about the reasons for health inequalities as well as the best possible instruments to measure both inequality and socioeconomic health gradients. We provide an evaluation of the different sources of health inequity and we draw upon measurement issues and their policy significance.     

Evaluation of the mandatory child abuse course for physicians: do we need to repeat it?

INTRODUCTION: Child abuse is one of the most common disorders affecting children of all ages. The objective of this study was to measure and assess the effectiveness of the mandated New York State child abuse and maltreatment course, and to identify and define the need for a refresher course. METHODS: This study was conducted in two parts. Part 1 consisted of a web-based survey among the paediatric members of 'Physicians Online' in New York State, and Part 2 consisted of an anonymous questionnaire survey using conventional US mail among the registered physicians in New York State who took the mandatory 'Recognition of Child Abuse and Maltreatment Course' between January 1988 and December 1998. The questionnaire included demographic information, test questions, and opinions of the physicians regarding the need for a refresher course. RESULTS: The web survey yielded 239/664 (36%) responses in 1 week. Approximately 45% of the respondents agreed that participation in the course produced a significant difference in their knowledge base and recommended that the course should be repeated every 5 years. The response rate for the mail survey was 56% (424/756). Among the respondents, 88% agreed that participation in the course produced an increased source of knowledge and practice (mean score of 3.2 +/- 1.2 using a scale of 1-5; where 1 = disagree and 5 = agree). The time since the course was taken (1-5 years vs >5 years ago) did not significantly influence their responses. Although 84% of the respondents answered the test questions correctly, significant differences were noted across practice specialty (P<0.05). In response to the question regarding the necessity for a refresher course, the mean score was 2.55 +/- 1.6 using a linear scale of 0-5 (where 0 = strongly disagree and 5 = strongly agree). CONCLUSIONS: These data suggest that practice specialty, not the time since the course was taken, made a significant difference in the knowledge of recognition and reporting of child abuse.     

Tackling rare diseases at European level: why do we need a harmonized framework?

Since 1999 the European Commission has gradually developed a proactive approach towards rare diseases (RD). Despite the progress made over the last years, a comprehensive and evidence based approach is still missing in many EU Member States (MS), leading to an incomplete and often inadequate framework to address rare diseases. Healthcare systems in EU MS differ to great extent among countries in respect to their organization and funding. In general, they are not ready to face the specific problems and needs of people with rare diseases for possible prevention, timely diagnosis, adequate treatment and rehabilitation. Access to new advanced treatment and approved orphan drugs by EMEA is also a big challenge for many MS. A public health approach is needed to properly tackle rare diseases. It is a while that the idea of a comprehensive approach addressing the different challenges of rare diseases is under discussion. In our opinion, the first step to build a comprehensive approach is to properly plan the activities to undertake accordingly to needs, gaps and resources available in a Country. It is therefore important to develop a strategic plan. Adopting a strategic planning approach to rare diseases implies taking advantage of ongoing actions and building on it to adjust, re-orient or expand the response. So far only France has developed a national strategic plan for rare diseases, Bulgaria is in the process of approving its national plan for RD and Spain is in the process of developing it. In this context, considering the importance of developing national plans for RD, it would be very useful to develop recommendations for RD national plan development in order to provide an instrument to support Countries in designing their national plans. The three MS initiatives presented in this paper confirmed the availability of great experiences and expertises among many EU MS and supported the idea that all these different experiences available at the EU level should form the basis for developing recommendations on how to develop strategic plans for RD. The recommendations will provide an instrument to support Countries in designing national plans contributing to the development of a harmonised and evidence based approach for addressing RD in EU MS. The elaboration of a European Commission Communication on rare diseases will ensure that common policy guidelines are shared everywhere in Europe. The availability of recommendations for developing national plans on rare diseases will link MS efforts with a common strategy at European level.     

Can you do a community assessment without talking to the community?

Conventionally, it has been accepted that an accurate understanding of community views on health topics can only come directly from community members. Yet, even as the need for this data has been increased by managed care, the methods of gathering it from community members remain costly and impractical for most busy practices or communities. This case study was conducted to determine whether well- informed health professionals can accurately and less expensively convey community views on health topics. In a low-income urban community, using a standard set of open-ended questions, focus groups and telephone and mail surveys were used to gather qualitative data from community residents and patients. Extended interviews and key informant surveys were used to gather similar data from health professionals. Data obtained from both sets of respondents were compared for content and logistics of collection. Overall, responses from the two groups had similar content but differing emphases. Community residents tended to emphasize socioeconomic determinants of health and everyday life concerns, while health care workers tended to emphasize the process of care. However, these perspectives were shared across the groups, as was an emphasis on the need for education with regard to community health concerns. The most striking difference between the groups was the community resources each group identified. As expected, costs for the health care worker approaches were less expensive. Findings from this case study suggest limited situations in which health care workers can adequately convey community views. In other situations, the different perspectives of each group can be complementary. Regardless of their role in qualitative data gathering, there remain important roles for community members in planning and decision-making regarding their health care.