The feasibility of task-sharing the identification,emergency treatment,and referral for women with pre-eclampsia by community health workers in India

Background

Hypertensive disorders are the second highest direct obstetric cause of maternal death after haemorrhage, accounting for 14% of maternal deaths globally. Pregnancy hypertension contributes to maternal deaths, particularly in low- and middle-income countries, due to a scarcity of doctors providing evidence-based emergency obstetric care. Task-sharing some obstetric responsibilities may help to reduce the mortality rates. This study was conducted to assess acceptability by the community and other healthcare providers, for task-sharing by community health workers (CHW) in the identification and initial care in hypertensive disorders in pregnancy.

Methods

This study was conducted in two districts of Karnataka state in south India. A total of 14 focus group discussions were convened with various community representatives: women of reproductive age (N = 6), male decision-makers (N = 2), female decision-makers (N = 3), and community leaders (N = 3). One-to-one interviews were held with medical officers (N = 2), private healthcare OBGYN specialists (N = 2), senior health administrators (N = 2), Taluka (county) health officers (N = 2), and obstetricians (N = 4). All data collection was facilitated by local researchers familiar with the setting and language. Data were subsequently transcribed, translated and analysed thematically using NVivo 10 software.

Results

There was strong community support for home visits by CHW to measure the blood pressure of pregnant women; however, respondents were concerned about their knowledge, training and effectiveness. The treatment with oral antihypertensive agents and magnesium sulphate in emergencies was accepted by community representatives but medical practitioners and health administrators had reservations, and insisted on emergency transport to a higher facility. The most important barriers for task-sharing were concerns regarding insufficient training, limited availability of medications, the questionable validity of blood pressure devices, and the ability of CHW to correctly diagnose and intervene in cases of hypertensive disorders of pregnancy.

Conclusion

Task-sharing to community-based health workers has potential to facilitate early diagnosis of the hypertensive disorders of pregnancy and assist in the provision of emergency care. We identified some facilitators and barriers for successful task-sharing of emergency obstetric care aimed at reducing mortality and morbidity due to hypertensive disorders of pregnancy.

     

Predictors of delayed culture conversion in patients treated for multidrug-resistant tuberculosis in Pakistan

Culture conversion is an interim monitoring tool for treatment of multidrug-resistant tuberculosis (MDR-TB). We evaluated the time to and predictors of culture conversion in pulmonary MDR-TB patients enrolled in the community-based MDR-TB management program at the Indus Hospital in Karachi, Pakistan. Despite strict daily directly observed therapy, monthly food incentives and patient counseling, the median time to culture conversion was 196 days (range 32-471). The cumulative probabilities of culture conversion by 2, 4, 6 and 12 months were respectively 6%, 33%, 47%, and 73%. Smoking, high smear grade at baseline and previous use of second-line drugs delayed culture conversion.     

Assessing Home Environment for Early Child Development in Pakistan

Family environment plays a very important role in early child development and the availability of stimulating material in the early years of a child's life is crucial for optimising development. The Home Observation for Measurement of the Environment (HOME) inventory is one of the most widely used measures to assess the quality and quantity of support and stimulation provided for children at home. This cross-sectional study aims to measure the existing situation of home environment with respect to child development using the HOME scale in two communities of Pakistan: TandoJam (Sindh) and Mastung (Baluchistan). From December 2009 until May 2010, all mothers with children from birth to age three were recruited for the study. Data on the home environment were collected from a cohort of 1,097 children using the Infant and Toddler HOME (IT-HOME) scale, further distributed over six subscales. Frequency distributions of all responses and mean and standard deviation for all subscales were calculated. The mean ± standard deviation age of study children was 16.6 ± 12.1 months. Overall, the mean score on the HOME scale was 31.7 ± 7.2 and 29.7 ± 6.9 in TandoJam and Mastung respectively. On a subscale level, about one-half of the families in TandoJam and three-quarters in Mastung scored in the lowest quarter category on the Learning Material subscale, whereas 41% of families in Mastung and 18% of families in TandoJam were in the lowest quarter on the Organization subscale. On the remaining three scales (Responsivity, Involvement and Variety) at least 50% of families scored in the upper quarter category. In conclusion, considerable evidence is available showing that poor home environment retards intellectual growth. The HOME inventory identified up to 23% of young children in the lowest quarter category who are potentially at risk of developmental delays. There is a need to develop culturally acceptable, evidence-based parenting interventions to improve the home environment.     

Defining the cultural milieu for implementing faculty practice in Pakistan

Faculty practice can promote a collaborative partnership mutually beneficial to both nursing education and service. However, little is known about its implementation in developing countries. The purpose of this study was to explore the potential for introducing faculty practice within the cultural milieu of Karachi, Pakistan. Focus groups of nursing faculty, staff and students were conducted in various settings: government, semigovernment and private institutions to elicit the data. Data analysis revealed that a more comprehensive definition of faculty practice is needed that will provide the foundation for a culturally acceptable model of faculty practice in Pakistan. Hierarchy dominates the current cultural milieu and must be addressed before faculty practice can be implemented.     

A university-sponsored home health nursing program in Karachi, Pakistan

This article describes a university-sponsored home health nursing program in a large urban center in Pakistan and details the essential elements needed in implementing such a program in a developing country. Compared to in-hospital treatment, home healthcare reduced hospital stay from 12.8 days to 3.9 days, and resulted in a net savings of Pakistani rupees (PRs) 5,374,135 (USD 89,569). A cost-effective home treatment program in a resource-limited country can be successfully implemented by using the hospital pharmacy as the central point for the preparation and distribution of medications and specialty nursing services.