Delivery cost of human papillomavirus vaccination of young adolescent girls in Peru,Uganda and Viet Nam

Objective

To estimate the incremental delivery cost of human papillomavirus (HPV) vaccination of young adolescent girls in Peru, Uganda and Viet Nam.

Methods

Data were collected from a sample of facilities that participated in five demonstration projects for HPV vaccine delivery: school-based delivery was used in Peru, Uganda and Viet Nam; health-centre-based delivery was also used in Viet Nam; and integrated delivery, which involved existing health services, was also used in Uganda. Microcosting methods were used to guide data collection on the use of resources (i.e. staff, supplies and equipment) and data were obtained from government, demonstration project and health centre administrative records. Delivery costs were expressed in 2009 United States dollars (US$). Exclusively project-related expenses and the cost of the vaccine were excluded.

Findings

The economic delivery cost per vaccine dose ranged from US$ 1.44 for integrated outreach in Uganda to US$ 3.88 for school-based delivery in Peru. In Viet Nam, the lowest cost per dose was US$ 1.92 for health-centre-based delivery. Cost profiles revealed that, in general, the largest contributing factors were project start-up costs and recurrent personnel costs. The delivery cost of HPV vaccine was higher than published costs for traditional vaccines recommended by the Expanded Programme on Immunization (EPI).

Conclusion

The cost of delivering HPV vaccine to young adolescent girls in Peru, Uganda and Viet Nam was higher than that for vaccines currently in the EPI schedule. The cost per vaccine dose was lower when delivery was integrated into existing health services.     

Stimulating the development of national Streptococcus suis guidelines in Viet Nam through a strategic research partnership

Problem

Streptococcus suis is a common cause of adult bacterial meningitis in Viet Nam, and possibly other parts of Asia, yet this disabling infection has been largely neglected. Prevention, diagnosis and treatment are relatively straightforward and affordable but, in early 2007, no national diagnostic, case management or prevention guidelines existed in Viet Nam.

Approach

Enhanced detection of S. suis infections was established in 2007 as part of a collaborative research programme between the National Hospital for Tropical Diseases, a key national hospital with very close links to the Ministry of Health, and a research group affiliated with Oxford University based in Viet Nam. The results were reported directly to policy-makers at the Ministry of Health.

Local setting

Viet Nam is a low-income country with a health-care system that has seen considerable improvements and increased autonomy. However, parts of the system remain fairly centralized the Ministry of Health.

Relevant changes

Following the improved detection and reporting of S. suis cases, the Ministry of Health issued guidance to all hospitals in Viet Nam on the clinical and laboratory diagnosis, treatment and prevention of S. suis. A public health laboratory diagnostic service was established at the National Institute of Hygiene and Epidemiology and training courses were conducted for clinicians and microbiologists. Ministry of Health guidance on surveillance and control of communicable diseases was updated to include a section on S. suis.

Lessons learnt

Research collaborations can efficiently inform and influence national responses if they are well positioned to reach policy-makers.     

Time to unsuccessful tuberculosis treatment outcome,Cambodia, China,and Viet Nam

Objective:

To determine the frequency and characteristics of patients with unsuccessful tuberculosis (TB) treatment.

Methods:

Random selection of TB case registers among all treatment units in Cambodia, two provinces in China, and Viet Nam. The data of two calendar years were analyzed to assess unsuccessful outcomes and their time of occurrence.

Results:

Among the 33 309 TB patients, treatment was unsuccessful in respectively 10.1%, 3.0% and 9.1% of patients in Cambodia, China and Viet Nam. The risk of death was highest in Cambodia, higher among males than females, increased with age, and was more common among retreatment cases than new cases, and among patients with a high than a low sputum smear microscopy grade. Half of all deaths occurred in the first 2 months in Cambodia and within 11 weeks in China and Viet Nam. Median time to default was 3 months in Cambodia and Viet Nam, and about 2 months in China.

Conclusions:

Treatment was highly successful in the three study countries, with a low proportion of death and default. As the majority of defaulting occurs at the beginning of treatment, all countries should critically review their current policy of treatment support in this period.     

Health Care Utilization and Costs Associated with Adherence to Clinical Practice Guidelines for Early Magnetic Resonance Imaging among Workers with Acute Occupational Low Back Pain

Objective

To estimate health care utilization and costs associated with adherence to clinical practice guidelines for the use of early magnetic resonance imaging (MRI; within the first 6 weeks of injury) for acute occupational low back pain (LBP).

Data Sources

Washington State Disability Risk Identification Study Cohort (D-RISC), consisting of administrative claims and patient interview data from workers’ compensation claimants (2002–2004).

Study Design

In this prospective, population-based cohort study, we compared health care utilization and costs among workers whose imaging was adherent to guidelines (no early MRI) to workers whose imaging was not adherent to guidelines (early MRI in the absence of red flags).

Data Collection/Extraction Methods

We identified workers (age >18) with work-related LBP using administrative claims. We obtained demographic, injury, health, and employment information through telephone interviews to adjust for baseline differences between groups. We ascertained health care utilization and costs from administrative claims for 1 year following injury.

Principal Findings

Of 1,770 workers, 336 (19.0 percent) were classified as nonadherent to guidelines. Outpatient and physical/occupational therapy utilization was 52–54 percent higher for workers whose imaging was not adherent to guidelines compared to workers with guideline-adherent imaging; utilization of chiropractic care was significantly lower (18 percent).

Conclusions

Nonadherence to guidelines for early MRI was associated with increased likelihood of lumbosacral injections or surgery and higher costs for out-patient, inpatient, and nonmedical services, and disability compensation.     

Common perinatal mental disorders in northern Viet Nam: community prevalence and health care use

Objective

To establish the prevalence of common perinatal mental disorders their determinants, and their association with preventive health care use among women in one rural and one urban province in northern Viet Nam.

Methods

We conducted a cross-sectional survey of cohorts of pregnant women and mothers of infants recruited systematically in 10 randomly-selected communes. The women participated in psychiatrist-administered structured clinical interviews and separate structured interviews to assess sociodemographic factors, reproductive health, the intimate partner relationship, family violence and the use of preventive and psychiatric health care. Associations between these variables and perinatal mental disorders were explored through univariate analyses and multivariable logistic regression.

Findings

Among women eligible for the study (392), 364 (93%) were recruited. Of these, 29.9% (95% confidence interval, CI: 25.20–34.70) were diagnosed with a common perinatal mental disorder (CPMD). The frequency of such disorders during pregnancy and in the postpartum period was the same. Their prevalence was higher among women in rural provinces (odds ratio, OR: 2.17; 95% CI: 1.19–3.93); exposed to intimate partner violence (OR: 2.11; 95% CI: 1.12–3.96); fearful of other family members (OR: 3.36; 95% CI: 1.05–10.71) or exposed to coincidental life adversity (OR: 4.40; 95% CI: 2.44–7.93). Fewer women with a CPMD used iron supplements than women without a CPMD, but the results were not statistically significant (P = 0.05). None of the women studied had ever received mental health care.

Conclusion

Perinatal depression and anxiety are prevalent in women in northern Viet Nam. These conditions are predominantly determined by social factors, including rural residence, poverty and exposure to family violence. At present the needs of women with common perinatal mental disorders are unrecognized and not attended to and their participation in essential antenatal preventive care appears to be compromised.     

Management of asthma in Benin: the challenge of loss to follow-up

Setting:

An asthma pilot project in Benin.

Objective:

To assess the implementation of standard case management of asthma at three referral centres and three primary care centres.

Methods:

The project began with local adaptation of international asthma guidelines, followed by situation analysis, pre-intervention, training and intervention. The initial dosage of inhaled beclometasone was determined by asthma severity. Outcome of treatment was assessed annually, starting from one year after enrolment.

Results:

Of 103 asthma patients identified during situation analysis, only 11 (11%) were prescribed inhaled corticosteroids. After health worker training, a total of 430 asthma patients were identified in 2008, of whom 273 (63.5%) returned after initial management with 7-day oral prednisolone. Of the 273 patients, 261 (95.6%) had persistent asthma, 231 (86.2%) had peak flow measurement variability of ≥20%, and 155 (56.8%) had had one or more unplanned visits to health facilities in the previous year. Outcome at one year evaluation was as follows: 63 (24.1%) had improved, 48 (18.4%) remained stable, 14 (5.4%) were worse and 136 (52.4%) were lost to follow-up.

Conclusion:

It is feasible to train health workers to manage asthma patients in a standardised manner. However, a high proportion of patients were lost to follow-up during treatment.     

Multiple types of child maltreatment and adolescent mental health in Viet Nam

Objective

To examine the prevalence of multiple types of maltreatment (MTM), potentially confounding factors and associations with depression, anxiety and self-esteem among adolescents in Viet Nam.

Methods

In 2006 we conducted a cross-sectional survey of 2591 students (aged 12–18 years; 52.1% female) from randomly-selected classes in eight secondary schools in urban (Hanoi) and rural (Hai Duong) areas of northern Viet Nam (response rate, 94.7%). Sequential multiple regression analyses were performed to estimate the relative influence of individual, family and social characteristics and of eight types of maltreatment, including physical, emotional and sexual abuse and physical or emotional neglect, on adolescent mental health.

Findings

Females reported more neglect and emotional abuse, whereas males reported more physical abuse, but no statistically significant difference was found between genders in the prevalence of sexual abuse. Adolescents were classified as having nil (32.6%), one (25.9%), two (20.7%), three (14.5%) or all four (6.3%) maltreatment types. Linear bivariate associations between MTM and depression, anxiety and low self-esteem were observed. After controlling for demographic and family factors, MTM showed significant independent effects. The proportions of the variance explained by the models ranged from 21% to 28%.

Conclusion

The combined influence of adverse individual and family background factors and of child maltreatment upon mental health in adolescents in Viet Nam is consistent with research in non-Asian countries. Emotional abuse was strongly associated with each health indicator. In Asian communities where child abuse is often construed as severe physical violence, it is important to emphasize the equally pernicious effects of emotional maltreatment.     

The formulation and implementation of a national helmet law: a case study from Viet Nam

Problem

Road traffic injuries are a leading cause of death and disability in Viet Nam. In 2008, official data reported 11 243 deaths and 7771 serious injuries on the roads, of which an estimated 60% of fatalities occur in motorcycle riders and passengers. In recognition of this problem, Viet Nam has had partial motorcycle helmet legislation since 1995. However, for a variety of reasons, implementation and enforcement have been limited.

Approach

On 15 December 2007, Viet Nam''s first comprehensive mandatory helmet law came into effect, covering all riders and passengers on all roads nationwide. Penalties increased ten-fold and cohorts of police were mobilized for enforcement.

Local setting

The Viet Nam national helmet legislation was developed and implemented by the National Traffic Safety Committee.

Relevant changes

Despite past barriers to enforcement, increased policing in 2008 led to 680 000 infringements being issued for non-helmet wearing. While changes in helmet wearing were not nationally observed, significant increases were documented in selected provinces in the first six months of the law’s introduction. In Da Nang, helmet wearing increased from 27 to 99%. In the first three months after the law took effect, surveillance data from 20 urban and rural hospitals, found the risk of road traffic head injuries and deaths decreased by 16% and 18% respectively.

Lessons learnt

Political leadership, intensive advanced public education and stringent enforcement have contributed to the successful implementation of the new law. Through continual monitoring of the legislation, loopholes detrimental to the effectiveness of the law have been identified and addressed.     

Post-licensure deployment of oral cholera vaccines: a systematic review

Objective

To describe and analyse the characteristics of oral cholera vaccination campaigns; including location, target population, logistics, vaccine coverage and delivery costs.

Methods

We searched PubMed, the World Health Organization (WHO) website and the Cochrane database with no date or language restrictions. We contacted public health personnel, experts in the field and in ministries of health and did targeted web searches.

Findings

A total of 33 documents were included in the analysis. One country, Viet Nam, incorporates oral cholera vaccination into its public health programme and has administered approximately 10.9 million vaccine doses between 1997 and 2012. In addition, over 3 million doses of the two WHO pre-qualified oral cholera vaccines have been administered in more than 16 campaigns around the world between 1997 and 2014. These campaigns have either been pre-emptive or reactive and have taken place under diverse conditions, such as in refugee camps or natural disasters. Estimated two-dose coverage ranged from 46 to 88% of the target population. Approximate delivery cost per fully immunized person ranged from 0.11–3.99 United States dollars.

Conclusion

Experience with oral cholera vaccination campaigns continues to increase. Public health officials may draw on this experience and conduct oral cholera vaccination campaigns more frequently.     

Catastrophic health expenditure on acute coronary events in Asia: a prospective study

Objective

To estimate out-of-pocket costs and the incidence of catastrophic health expenditure in people admitted to hospital with acute coronary syndromes in Asia.

Methods

Participants were enrolled between June 2011 and May 2012 into this observational study in China, India, Malaysia, Republic of Korea, Singapore, Thailand and Viet Nam. Sites were required to enrol a minimum of 10 consecutive participants who had been hospitalized for an acute coronary syndrome. Catastrophic health expenditure was defined as out-of-pocket costs of initial hospitalization > 30% of annual baseline household income, and it was assessed six weeks after discharge. We assessed associations between health expenditure and age, sex, diagnosis of the index coronary event and health insurance status of the participant, using logistic regression models.

Findings

Of 12 922 participants, 9370 (73%) had complete data on expenditure. The mean out-of-pocket cost was 3237 United States dollars. Catastrophic health expenditure was reported by 66% (1984/3007) of those without insurance versus 52% (3296/6366) of those with health insurance (P < 0.05). The occurrence of catastrophic expenditure ranged from 80% (1055/1327) in uninsured and 56% (3212/5692) of insured participants in China, to 0% (0/41) in Malaysia.

Conclusion

Large variation exists across Asia in catastrophic health expenditure resulting from hospitalization for acute coronary syndromes. While insurance offers some protection, substantial numbers of people with health insurance still incur financial catastrophe.     

Effects of Health Guidance on Outpatient and Pharmacy Expenditures: A Disease- and Drug-Specific 3-Year Observational Study Using Propensity-Score Matching

Background

Evidence is lacking on whether health guidance for metabolic syndrome reduces health care expenditures. The author used propensity-score matching to evaluate the effects of health guidance on health care expenditure.

Methods

Men who did and did not receive health guidance from a health insurance society (approximately 60 000 covered lives) were matched (n = 397 respectively) using propensity scores. Health insurance claims were compared using cumulative health care expenditures for metabolic syndrome-related outpatient medical care and drug costs for the period from the initial consultation to 3 years later.

Results

No difference was observed between intervention and control groups in cumulative outpatient charges or drug costs related to metabolic syndrome. However, regression analysis using the Tobit model showed that health guidance resulted in a small, nonsignificant reduction in health care expenditure.

Conclusions

Health guidance for metabolic syndrome did not reduce outpatient charges or drug costs related to metabolic syndrome during the 3-year period after the intervention. Findings from Tobit regression suggest that health guidance might eventually result in savings, but this hypothesis remains untested.Key words: health guidance, health insurance claims, propensity-score matching, PDM (proportional distribution method), metabolic syndrome     

Iodine status in late pregnancy and psychosocial determinants of iodized salt use in rural northern Viet Nam

Objective

To establish iodine status among pregnant women in rural northern Viet Nam and explore psychosocial predictors of the use of iodized salt in their households.

Methods

This prospective study included pregnant women registered in health stations in randomly-selected communes in Ha Nam province. At recruitment (< 20 weeks of gestation), sociodemographic factors, reproductive health, intimate partner relationship, family violence, symptoms of common mental disorders and use of micronutrient supplements were assessed. During a second assessment (> 28 weeks of gestation) a urine specimen was collected to measure urinary iodine concentration (UIC) and iodized salt use was assessed. Predictors were explored through univariable analyses and multivariable linear and logistic regression.

Findings

The 413 pregnant women who provided data for this study had a median UIC of 70 µg/l; nearly 83% had a UIC lower than the 150 µg/l recommended by the World Health Organization; only 73.6% reported using iodized salt in any form in their households. Iodized salt use was lower among nulliparous women (odds ratio, OR: 0.56; 95% confidence interval, CI: 0.32–0.96); less educated women (OR: 0.34; 95% CI: 0.16–0.71); factory workers or small-scale traders (OR: 0.52; 95% CI: 0.31–0.86), government workers (OR: 0.35; 95% CI: 0.13–0.89) and women with common mental disorders at recruitment (OR: 0.61; 95% CI: 0.38–0.98).

Conclusion

The decline in the use of iodized salt in Viet Nam since the National Iodine Deficiency Disorders Control Programme was suspended in 2005 has placed pregnant women and their infants in rural areas at risk of iodine deficiency disorders.     

Influenza seasonality and vaccination timing in tropical and subtropical areas of southern and south-eastern Asia

Objective

To characterize influenza seasonality and identify the best time of the year for vaccination against influenza in tropical and subtropical countries of southern and south-eastern Asia that lie north of the equator.

Methods

Weekly influenza surveillance data for 2006 to 2011 were obtained from Bangladesh, Cambodia, India, Indonesia, the Lao People''s Democratic Republic, Malaysia, the Philippines, Singapore, Thailand and Viet Nam. Weekly rates of influenza activity were based on the percentage of all nasopharyngeal samples collected during the year that tested positive for influenza virus or viral nucleic acid on any given week. Monthly positivity rates were then calculated to define annual peaks of influenza activity in each country and across countries.

Findings

Influenza activity peaked between June/July and October in seven countries, three of which showed a second peak in December to February. Countries closer to the equator had year-round circulation without discrete peaks. Viral types and subtypes varied from year to year but not across countries in a given year. The cumulative proportion of specimens that tested positive from June to November was > 60% in Bangladesh, Cambodia, India, the Lao People''s Democratic Republic, the Philippines, Thailand and Viet Nam. Thus, these tropical and subtropical countries exhibited earlier influenza activity peaks than temperate climate countries north of the equator.

Conclusion

Most southern and south-eastern Asian countries lying north of the equator should consider vaccinating against influenza from April to June; countries near the equator without a distinct peak in influenza activity can base vaccination timing on local factors.     

A hospital-based tuberculosis focal point to improve tuberculosis care provision in a very high burden setting

Setting:

A hospital-based tuberculosis focal point (TBFP) at a tertiary hospital in Johannesburg, South Africa.

Objective:

To describe the possible tasks and impact of a hospital-based TBFP as well as staffing and infrastructure requirements for setting up a hospital-based TBFP.

Activities:

A TBFP can centralize the notification and referral of new TB cases, perform human immunodeficiency virus counseling and testing, assessment of difficult to diagnose TB suspects and management of complicated TB cases, and it can provide an ideal setting for research and health care worker training.

Results:

The number of TB suspects assessed by sputum initially increased, followed by a decrease starting in 2010, which correlates with the globally decreasing TB incidence. The proportion of TB cases who failed to link to TB care decreased from 23% to 14% between 2009 and 2012. Almost 40% of cases with hepatotoxicity required an adjusted treatment regimen. Roll-out of Xpert^® MTB/RIF testing and decentralized drug-resistant TB treatment increased the number of rifampicin monoresistant and sputum smear-negative multidrug-resistant TB cases treated on an out-patient basis.

Conclusion:

A hospital-based TBFP complements care at primary care level by coordinating TB care for a vulnerable population of patients diagnosed in a hospital setting, and by coordinating the diagnosis and treatment of complex TB cases.     

Severe malnutrition in children presenting to health facilities in an urban slum in Bangladesh

Setting:

An urban slum in Kamrangirchar, Bangladesh.

Objectives:

Among children aged 6–59 months seeking medical care from the two Médecins Sans Frontières-supported primary health centres, to determine 1) the prevalence of severe acute malnutrition (SAM) and severe chronic malnutrition (SCM), and 2) the extent of overlap between SAM and SCM.

Design:

In a retrospective record review, data were analysed from out-patient registers on age, sex, height, weight and mid-upper arm circumference (MUAC) of children attending for medical care from April to September 2011. SAM was defined as weight for height < −3 Z scores of the median and/or MUAC <115 mm. SCM was defined as height for age < −3 Z scores of the median. World Health Organization growth standards were used as reference.

Results:

Data were complete in the records of 7318 (98%) children, of whom 322 (4%) had SAM and 1698 (23%) had SCM. Among the 322 children with SAM, 162 (50%) also had SCM.

Conclusion:

In an urban Bangladesh slum, SAM and SCM co-exist, with a predominance of SCM. The current national guidelines for severe malnutrition, which focus on identification and management only for SAM, urgently need to be expanded to include SCM if substantial childhood morbidity and mortality are to be reduced.     

Viet Nam��s mandatory motorcycle helmet law and its impact on children

Objective

To measure the use of motorcycle helmets in children and to determine the reasons why children wear helmets less often than adults.

Methods

The frequency of helmet wearing among adults and children was ascertained by trained roadside observers, and randomized road user surveys were completed in four major centres in Viet Nam: Hanoi, Ho Chi Minh City, Can Tho and Da Nang. Survey data on key questions were cross tabulated, and χ² was calculated for significant differences between parents and non-parents (0.05).

Findings

The frequency of helmet use in the four study locations ranged from 90–99% among adults, from 15–53% among children ≤ 7 years of age, and from 38–53% among children > 7 but ≤ 14. Of the parents surveyed, 67% said the fear of neck injury was the most important reason their children did not wear a helmet.

Conclusion

Children wear motorcycle helmets much less often than adults. Legislation to penalize adults whose children do not wear motorcycle helmets has been proposed in Viet Nam. Furthermore, ongoing advocacy and social marketing efforts are being made to disseminate information about the safety benefits of helmets to combat erroneous public perceptions.     

Human papillomavirus vaccine delivery strategies that achieved high coverage in low- and middle-income countries

Objective

To assess human papillomavirus (HPV) vaccination coverage after demonstration projects conducted in India, Peru, Uganda and Viet Nam by PATH and national governments and to explore the reasons for vaccine acceptance or refusal.

Methods

Vaccines were delivered through schools or health centres or in combination with other health interventions, and either monthly or through campaigns at fixed time points. Using a two-stage cluster sample design, the authors selected households in demonstration project areas and interviewed over 7000 parents or guardians of adolescent girls to assess coverage and acceptability. They defined full vaccination as the receipt of all three vaccine doses and used an open-ended question to explore acceptability.

Findings

Vaccination coverage in school-based programmes was 82.6% (95% confidence interval, CI: 79.3–85.6) in Peru, 88.9% (95% CI: 84.7–92.4) in 2009 in Uganda and 96.1% (95% CI: 93.0–97.8) in 2009 in Viet Nam. In India, a campaign approach achieved 77.2% (95% CI: 72.4–81.6) to 87.8% (95% CI: 84.3–91.3) coverage, whereas monthly delivery achieved 68.4% (95% CI: 63.4–73.4) to 83.3% (95% CI: 79.3–87.3) coverage. More than two thirds of respondents gave as reasons for accepting the HPV vaccine that: (i) it protects against cervical cancer; (ii) it prevents disease, or (iii) vaccines are good. Refusal was more often driven by programmatic considerations (e.g. school absenteeism) than by opposition to the vaccine.

Conclusion

High coverage with HPV vaccine among young adolescent girls was achieved through various delivery strategies in the developing countries studied. Reinforcing positive motivators for vaccine acceptance is likely to facilitate uptake.     

Comprehensiveness of primary services in the care of infectious tuberculosis patients in Rawalpindi,Pakistan

Setting:

All tuberculosis (TB) diagnostic centres of Rawalpindi District, Pakistan, including five tertiary care hospitals and 16 rural health centres.

Objective:

To identify among sputum smear-positive patients registered during 2009 in the laboratory register those who had not been recorded in a treatment register, defined in the study as ‘initial loss to follow-up’.

Design:

A retrospective record review of routine TB data.

Results:

There were 16 145 suspects screened for TB and recorded in the laboratory registers. Of 1698 smear-positive patients identified in the laboratory registers, 101 (6%) could not be identified in the treatment registers. Eighty-six (10%) of 842 patients in tertiary care hospitals and 15/856 (2%) in rural health centres were not recorded (OR 6.4, 95%CI 3.6–11.6, P < 0.01).

Conclusion:

The study shows a significant association between type of health facility and initial loss to follow-up. In rural health centres, the proportion lost to follow-up is low, reflecting more efficient care than in tertiary care hospitals. Strategies are urgently needed to improve the registration and follow-up of smear-positive cases in tertiary care institutions.     

The principle of integrality of care in the political-pedagogical projects of nursing programs

Objective:

to identify the political-pedagogical projects of the undergraduate nursing programs in Santa Catarina, Brazil according to the guidelines of the Ministries of Health and Education, considering the education of professionals under the principle of integrality.

Method:

documentary study with a qualitative approach. Nine projects were analyzed.

Results:

the colleges from the Southern region of Brazil are gradually incorporating the theoretical framework of the Brazilian health system and curricular guidelines, which includes the principle of integrality of care, into their political-pedagogical projects of undergraduate nursing programs. Some institutions strictly follow the curricular guidelines, while others make their own interpretation.

Conclusion:

most teaching institutions do not provide pedagogical support to students.