Experience of targeting subsidies on insecticide-treated nets: what do we know and what are the knowledge gaps?

Widespread coverage of vulnerable populations with insecticide-treated nets (ITNs) constitutes an important component of the Roll Back Malaria (RBM) strategy to control malaria. The Abuja Targets call for 60% coverage of children under 5 years of age and pregnant women by 2005; but current coverage in Africa is unacceptably low. The RBM 'Strategic Framework for Coordinated National Action in Scaling-up Insecticide-Treated Netting Programmes in Africa' promotes coordinated national action and advocates sustained public provision of targeted subsidies to maximise public health benefits, alongside support and stimulation of the private sector. Several countries have already planned or initiated targeted subsidy schemes either on a pilot scale or on a national scale, and have valuable experience which can inform future interventions. The WHO RBM 'Workshop on mapping models for delivering ITNs through targeted subsidies' held in Zambia in 2003 provided an opportunity to share and document these country experiences. This paper brings together experiences presented at the workshop with other information on experiences of targeting subsidies on ITNs, net treatment kits and retreatment services (ITN products) in order to describe alternative approaches, highlight their similarities and differences, outline lessons learnt, and identify gaps in knowledge. We find that while there is a growing body of knowledge on different approaches to targeting ITN subsidies, there are significant gaps in knowledge in crucial areas. Key questions regarding how best to target, how much it will cost and what outcomes (levels of coverage) to expect remain unanswered. High quality, well-funded monitoring and evaluation of alternative approaches to targeting ITN subsidies is vital to develop a knowledge base so that countries can design and implement effective strategies to target ITN subsidies.     

Efficacy and cost-effectiveness of environmental management for malaria control

Roll back malaria (RBM) aims at halving the current burden of the disease by the year 2010. The focus is on sub-Saharan Africa, and it is proposed to implement efficacious and cost-effective control strategies. But the evidence base of such information is scarce, and a notable missing element is the discussion of the potential of environmental management. We reviewed the literature and identified multiple malaria control programmes that incorporated environmental management as the central feature. Prominent among them are programmes launched in 1929 and implemented for two decades at copper mining communities in Zambia. The full package of control measures consisted of vegetation clearance, modification of river boundaries, draining swamps, oil application to open water bodies and house screening. Part of the population also was given quinine and was sleeping under mosquito nets. Monthly malaria incidence rates and vector densities were used for surveillance and adaptive tuning of the environmental management strategies to achieve a high level of performance. Within 3-5 years, malaria-related mortality, morbidity and incidence rates were reduced by 70-95%. Over the entire 20 years of implementation, the programme had averted an estimated 4173 deaths and 161,205 malaria attacks. The estimated costs per death and malaria attack averted were US$ 858 and US$ 22.20, respectively. Over the initial 3-5 years start-up period, analogous to the short-duration of cost-effectiveness analyses of current studies, we estimated that the costs per disability adjusted life year (DALY) averted were US$ 524-591. However, the strategy has a track record of becoming cost-effective in the longer term, as maintenance costs were much lower: US$ 22-92 per DALY averted. In view of fewer adverse ecological effects, increased sustainability and better uses of local resources and knowledge, environmental management--integrated with pharmacological, insecticidal and bednet interventions--could substantially increase the chances of rolling back malaria.     

A randomized trial comparing a group exercise programme for back pain patients with individual physiotherapy in a severely deprived area

Purpose. To compare a group exercise programme known as the Back to Fitness programme with individual physiotherapy for patients with non-specific low back pain from a materially deprived area.

Method. This was a randomized controlled trial including 237 physiotherapy patients with back pain lasting more than six weeks. Participants were allocated to either the Back to Fitness programme or to individual physiotherapy, and followed up at three months and 12 months after randomization. The main outcome measure was the Roland Disability Questionnaire. Secondary measures were: SF12, EQ5D, Pain Self-Efficacy Scale. Health care diaries recording patients' use of health care resources were also collected over a 12-month period.

Results. There were no statistically significant differences in change scores between groups on the primary outcome measure at three months (CI - 2.24 to 0.49) and at 12 months (CI - 1.68 to 1.39). Only minor improvements in disability scores were observed in the Back to Fitness group at three months and 12 months respectively (mean change scores; - 0.89, - 0.77) and in the individual physiotherapy arm (mean change scores; - 0.02, - 0.63). Further analysis showed that patients from the most severely deprived areas were marginally worse at three month follow-up whereas those from more affluent areas tended to improve (CI 0.43 to 3.15).     

Trends in use of opioids for non-cancer pain conditions 2000-2005 in commercial and Medicaid insurance plans: the TROUP study

Opioids are widely prescribed for non-cancer pain conditions (NCPC), but there have been no large observational studies in actual clinical practice assessing patterns of opioid use over extended periods of time. The TROUP (Trends and Risks of Opioid Use for Pain) study reports on trends in opioid therapy for NCPC in two disparate populations, one national and commercially insured population (HealthCore plan data) and one state-based and publicly-insured (Arkansas Medicaid) population over a six year period (2000–2005). We track enrollees with the four most common NCPC conditions: arthritis/joint pain, back pain, neck pain, headaches, as well as HIV/AIDS. Rates of NCPC diagnosis and opioid use increased linearly during this period in both groups, with the Medicaid group starting at higher rates and the HealthCore group increasing more rapidly. The proportion of enrollees receiving NCPC diagnoses increased (HealthCore 33%, Medicaid 9%), as did the proportion of enrollees with NCPC diagnoses who received opioids (HealthCore 58%, Medicaid 29%). Cumulative yearly opioid dose (in mg. morphine equivalents) received by NCPC patients treated with opioids increased (HealthCore 38%, Medicaid 37%) due to increases in number of days supplied rather than dose per day supplied. Use of short-acting Drug Enforcement Administration Schedule II opioids increased most rapidly, both in proportion of NCPC patients treated (HealthCore 54%, Medicaid 38%) and in cumulative yearly dose (HealthCore 95%, Medicaid 191%). These trends have occurred without any significant change in the underlying population prevalence of NCPC or new evidence of the efficacy of long-term opioid therapy and thus likely represent a broad-based shift in opioid treatment philosophy.     

Reliability and discriminatory capacity of a clinical scale for assessing abdominal muscle coordination

Objective

This study evaluated the reliability and discriminatory capacity of a novel clinical scale for assessing abdominal muscle coordination. We investigated the interrater reliability of this tool in patients with chronic low back pain (LBP) (reliability section); the ability of this tool to discriminate healthy and LBP subjects (discriminatory section); and the association between the score and measures of pain, disability, and kinesiophobia (correlation section).

Methods

For the reliability section of this study, 14 patients with chronic LBP were included. For the discriminatory section, 10 patients with chronic LBP and 10 pain-free controls were recruited. In the correlation study, data from the 10 chronic LBP patients in the discriminatory section were used. The clinical test was conducted by a blinded examiner while the subjects attempted to independently activate transversus abdominis separate from the rest of the abdominal muscles (hollowing or draw-in maneuver). The intraclass correlation coefficients, receiver operating characteristic curve, and Pearson r correlation coefficients were calculated to assess reliability and validity.

Results

An intraclass correlation coefficient_(2,1) of 0.72 (95% confidence interval, 0.33-0.90) was recorded for interrater reliability. The tool correctly identified the subject condition in 97% of the cases. The score did not correlate substantially with any clinical measures, with Pearson r ranging from 0.122 (P = .737) to 0.493 (P = .148).

Conclusions

This study showed that the proposed scale is a reliable tool and may be useful in discriminating patients with chronic LBP from pain-free controls. The poor correlation between the score and clinical measures may be due to the multidimensional nature of chronic LBP.     

Psychological response in spinal manipulation (PRISM): a systematic review of psychological outcomes in randomised controlled trials

BACKGROUND: The most important risk factors for back and neck pain are psychosocial. Nevertheless, systematic reviews of spinal manipulation have concentrated on pain and spine related disability, and ignored psychological outcomes. OBJECTIVE: To assess whether spinal manipulation was effective in improving psychological outcome. DESIGN: Systematic review of randomised controlled trials (RCTs). METHODS: RCTs were identified by searching Medline, CINAHL, Embase, CENTRAL, AMED, PsycINFO until November 2005. Trials reporting psychological outcomes including the mental health components of generic outcomes were extracted, and combined where appropriate in meta-analyses. RESULTS: One hundred and twenty nine RCTs of spinal manipulation were identified; 12 had adequately reported psychological outcomes. Six trials with a verbal intervention comparator were combined in a meta-analysis, and found a mean benefit from spinal manipulation equivalent to 0.34 of the population standard deviation (S.D.) [95% confidence interval (CI) 0.23-0.45] at 1-5 months; 0.27 of the S.D. [95% CI 0.14-0.40] at 6-12 months. Eight trials with a physical treatment comparator were combined in a meta-analysis and found a mean benefit of 0.13 of the S.D. [95% CI 0.01-0.24] in favour of manipulation at 1-5 months; 0.11 of the S.D. [95% CI -0.02 to 0.25] at 6-12 months. CONCLUSIONS: There was some evidence that spinal manipulation improved psychological outcomes compared with verbal interventions.     

Relationship between low back pain and life-stressing events among Nigerian and Caucasian patients

Objectives

Socio-economic status and life-stressing events have been shown to have ethnic and racial differences that exert a strong influence on care-seeking habits and recovery from low back pain (LBP). This study examined the relationship between life-stressing events and sensory and psychological attributes among Nigerian and Caucasian patients with LBP, and the influence of socio-economic status on this relationship.

Design

Stratified, single cohort questionnaire study.

Setting

Three outpatient physiotherapy clinics in Nigeria.

Participants

One hundred and sixty-five patients, including 107 Black Nigerians (age range 26-65 years, mean 52 years) and 58 Caucasians (age range 25-62 years, mean 41 years), with LBP of at least 6 weeks duration were recruited over a 9-year period.

Main outcome measures

The Low Back Pain Questionnaire, Social Re-adjustment Rating Scale, State-Trait Anxiety Inventory and Multiple Affect Adjective Check List. Socio-economic status and pain levels, on a 0-100 numerical rating scale, were also recorded. Questionnaires were administered within 5 days of the patient reporting at the clinic.

Results

Recorded pain intensity was similar in Nigerian [mean pain score 78, 95% confidence interval (CI) 73.4 to 83.4] and Caucasian (mean pain score 79, 95% CI 74.8 to 84.8) patients. Subjects who recorded higher numbers of life-stressing events on the Social Re-adjustment Rating Scale also recorded higher scores on a number of LBP attributes including hot, burning, bright, throbbing and pressure qualities. Pain intensity and state anxiety correlated significantly with life-stressing event scores among Caucasian patients, who were mainly of high socio-economic status. State and trait anxiety and emotional discomfort scores correlated significantly with life-stressing event scores among Nigerian patients, who were mainly of low to medium socio-economic status.

Conclusion

Most patients had experienced a number of life-stressing events, particularly those classified as being of low socio-economic status. Low socio-economic status patients who had experienced a high number of life-stressing events were more likely to show emotional and psychological symptoms, which may have influenced the reporting of the characteristics and history of their LBP. There is a need to assess these issues when managing LBP patients. Further research is required to determine how the outcome of treatment may be influenced by these factors.     

Comparing the rates of low-value back images ordered by physicians and nurse practitioners for Medicare beneficiaries in primary care

BackgroundLittle is known about the extent of ordering low-value services by.PurposeTo compare the rates of low-value back images ordered by primary care physicians (PCMDs) and primary care nurse practitioners (PCNPs).MethodWe used 2012 and 2013 Medicare Part B claims for all beneficiaries in 18 hospital referral ?regions (HRRs) and a measure of low-value back imaging from Choosing Wisely. Models included random clinician effect and fixed effects for beneficiary age, disability, Elixhauser comorbidities, clinician sex, the emergency department setting, back pain visit volume, organization, and region (HRR).FindingsPCNPs (N = 231) and PCMDs (N = 4,779) order low-value back images at similar rates (NP: all images: 26.5%; MRI/CT: 8.4%; MD: all images: 24.5%; MRI/CT: 7.7%), with no detectable significant difference when controlling for covariates.DiscussionPCNPs and PCMDs order low-value back images at an effectively similar rate.     

Back Muscle Function in Older Women With Age-Related Hyperkyphosis: A Comparative Study

ObjectiveThe purpose of this study was to compare static maximal back extensor muscle force, endurance, and characteristics of flexion relaxation phenomenon (FRP) in older women with and without age-related hyperkyphosis.MethodsMaximum back extensor force and endurance measured in a sitting position with a designed load cell setup; appearance, onset, and offset angles of FRP; and extension relaxation ratio (ERR) during a dynamic flexion-extension task were compared between 24 older women with hyperkyphosis (thoracic kyphosis angle ≥50°), mean age 65 ± 4.4 years, and 24 older women without hyperkyphosis (thoracic kyphosis angle ?50°), mean age 63 ± 4.3 years. Variables of force, endurance, angles of FRP, and ERR were analyzed using an independent sample t test. A χ² test was used to identify differences between groups in FRP appearance.ResultsStatic back extensor force and endurance were significantly lower among those with versus those without hyperkyphosis (P ? .001). Although the 2 groups did not differ in FRP appearance and ERR in the superficial erector spinal muscles (P ? .05), FRP in the hyperkyphosis group started sooner and ended later than in the group without hyperkyphosis (P ? .05).ConclusionOur study indicates that women with age-related hyperkyphosis had decreased static maximal force and endurance of the back extensor muscles and prolonged myoelectrical silence of the superficial erector spinal muscles. Reduced endurance of the superficial erector spinal muscles may trigger early onset of FRP and prolonged relaxation of these muscles.     

Kinesio Taping reduces pain and improves disability in low back pain patients: a randomised controlled trial

Objective

To investigate the effects of Kinesio Taping^® (KT) on chronic non-specific low back pain (LBP).