Effectiveness of diapers among people with chronic incontinence in Thailand

Objectives:
The aim of this study was to assess effect of adult diapers on health-related quality of life (HRQOL) and the independent level of performing activities of daily living (ADLs) in people with urinary or fecal incontinence. Psychological consequences of patients’ caregivers were also measured.
Methods:
This quasi-experimental study was conducted at two rehabilitation centers in Thailand. People aged 15 years or greater with chronic urinary or fecal incontinence were
eligible. Study participants received adult diapers for 10 weeks after recruitment. Thai EuroQol Five Dimensions (EQ-5D) and the Barthel Index were measured at baseline and weeks
2, 6, and 10 to evaluate HRQOL and the independent level of performing ADLs, respectively. The Braden Scale was used to assess the risk of having pressure ulcers. Mean
differences in the Thai EQ-5D, the Barthel Index, and the Braden Scale, before and after receiving adult diapers, were estimated using a multilevel linear regression model.
Results:
There were ninety patients and forty-eight caregivers who took part in this study. HRQOL and independent level of performing ADLs had improved significantly by week 10
after receiving adult diapers with mean differences of 0.102 (95% confidence interval [CI], 0.046–0.158) and 4.40 (95% CI, 1.74–7.07), respectively. The risk of having
pressure ulcers had significantly decreased by 67 percent (95% CI, 16 percent–78 percent) by week 10 after receiving adult diapers.
Conclusions:
The results indicate a significant improvement of HRQOL and the independent level of performing ADLs among incontinent patients after receiving adult diapers. These results were used to inform the development of the health benefits package under the Universal Health Coverage Scheme in Thailand.

Bellwether procedures for monitoring and planning essential surgical care in low- and middle-income countries: caesarean delivery, laparotomy and treatment of open fractures

BACKGROUND: Surgical conditions represent a significant proportion of the global burden of disease, and therefore, surgery is an essential component of health systems. Achieving universal health coverage requires effective monitoring of access to surgery. However, there is no widely accepted standard for the required capabilities of a first-level hospital. We aimed to determine whether a group of operations could be used to describe the delivery of essential surgical care.

METHODS: We convened an expert panel to identify procedures that might indicate the presence of resources needed to treat an appropriate range of surgical conditions at first-level hospitals. Using data from the World Health Organization Emergency and Essential Surgical Care Global database, collected using the WHO Situational Analysis Tool (SAT), we analysed whether the ability to perform each of these procedures-which we term "bellwether procedures"-was associated with performing a full range of essential surgical procedures.

FINDINGS: The ability to perform caesarean delivery, laparotomy, and treatment of open fracture was closely associated with performing all obstetric, general, basic, emergency, and orthopaedic procedures (p < 0.001) in the population that responded to the WHO SAT Survey. Procedures including cleft lip, cataract, and neonatal surgery did not correlate with performing the bellwether procedures.

INTERPRETATION: Caesarean delivery, laparotomy, and treatment of open fractures should be standard procedures performed at first-level hospitals. With further validation in other populations, local managers and health ministries may find this useful as a benchmark for what first-level hospitals can and should be able to perform on a 24/7 basis in order to ensure delivery of emergency and essential surgical care to their population. Those procedures which did not correlate with the bellwether procedures can be referred to a specialized centre or collected for treatment by a visiting specialist team.

Healthy markets - healthy people/ : reforming health care in Cambodia

Health care reform has been described as a global epidemic. This thesis deals with nature and experience of health care reform in developing countries. Increasing privatisation, economic transition, and structural adjustment have provided the context for health system changes. Different approaches to reform have been developed by international organisations such as the World Bank, WHO and UNICEF. What has driven national health care reforms? Are such policies really appropriate to developing countries? Has a consensus now emerged in relation to international health policy? Has a new health care ‘model’ appeared? The study of health care reform in Cambodia is a timely opportunity to investigate the implementation of health care reform under extreme conditions. These conditions include a legacy of genocide, long-term conflict, political isolation, and economic transition. This case study uses both qualitative and quantitative methods and multiple sources of data to analyse the reform program. The study reinforces the conclusion that, under conditions of extreme poverty, market based reforms are likely to have limited positive impact. Rather, understanding the cultural conditions that determine demand, delivering health care of a satisfactory quality, providing appropriate incentives for health practitioners, and supporting services with adequate public funding are the prerequisites for improved service delivery and utilisation. Cambodia's strategy of integrated district health service development and universal population coverage may provide an instructive example of reform. Emerging policy issues identified by this case study include the fundamental role of equity in service provision, the influence of the social determinants of health and illness and interest in the appropriate use of evidence in international health policy-making.

The 1947 bank nationalisation scheme : a prehistory of issues management?

Industry-wide crises emanating from legislative proposals are rare in Australia, and can be classed as once in a generation events, and so merit consideration and research. Currently, there is one such debate over the Mineral Resources Rent Tax, proposed by Prime Minister’s Julia Gillard’s government. Prior to this, the closest comparable event was the 1974 proposal for the establishment of a universal health insurance scheme. The 1947 proposal, by the Ben Chifley-led Labor Government, aimed to nationalise Australia’s banks, and it brought a crisis of massive proportions to Australia’s conservative financial service industry. Although the High Court of Australia finally found Chifley’s proposed legislation unconstitutional, the banks realised they must win in the court of public opinion, generate press coverage in favour of their position, and help defeat the Labor Government at the 1949 election. At the time, and for some decades to come, this was the most expensive and largest public relations campaign waged in Australia. After such a campaign there could be few Australians who could claim that they had not been exposed to the powers of public relations in a modern world. This paper looks at what can be learned from the banks’ collective response to the proposed nationalisation. It does so by applying contemporary issues management evaluation techniques.

Health consumer activism in Australia : the downside of state inclusion

Many community groups concerned with health issues - women's organisations, patient support groups and older citizens' organisations - were formed long before they were designated as 'consumer' groups. Members of health groups founded in the 1960s and 1970s understood themselves to be activists for social change, not 'consumers'. They challenged established models of health care and mobilised to redress inequities of access to care and inequalities of power between the medical profession and the 'lay' population. The major campaign in this period was to establish universal health insurance.

Use of eye care services by people with diabetes: the Melbourne Visual Impairment Project

AIM: The use of eye care services by people with and without diabetes was investigated in the Melbourne Visual Impairment Project (VIP), a population based study of eye disease in a representative sample of Melbourne residents 40 years of age and older. METHODS: A comprehensive interview was employed to elicit information on history of diabetes, medication use, most recent visit to an ophthalmologist and optometrist, and basic demographic details. Presence and extent of diabetic retinopathy was determined by dilated fundus examination. RESULTS: The Melbourne VIP comprised 3271 people who ranged in age from 40 to 98 years; 46.2% of them were male. Of 3189 people who had the fundus examination and knew their diabetes status, 162 (5.1%) reported having been previously diagnosed with diabetes and, of these, 37 (22.2%) were found to have diabetic retinopathy. Seven people (4.3%) had developed diabetes before age 30. The mean duration of diabetes was 9.2 years. People with diabetes were significantly more likely to have visited an ophthalmologist ever or in the past 2 years than people without diabetes. However, 31.8% of people with diabetes had never visited an ophthalmologist. The proportion of people who had never seen an ophthalmologist was 47.1% for people without diabetes, 34.2% for people with diabetes but without diabetic retinopathy, and 25% for people with diabetic retinopathy. Sixty one per cent of people with diabetic retinopathy had seen an ophthalmologist in the past year and a further 3% within the past 2 years. People with diabetes were not significantly more likely to have visited an optometrist than people without diabetes (p = 0.51). Overall, 37.7% of people with diabetes and 32.9% of people without diabetes had visited an optometrist within the past year (chi 2 = 2.25, 1 df, p = 0.13). Information concerning retinal examinations was available for 135 individuals (83.3% of people with diabetes). Only 74 (54.8%) could recall ever having a dilated fundus examination; 10 (14%) by an optometrist, 62 (86%) by an ophthalmologist, and five (7%) by a general practitioner. Of those 68 people who had seen an ophthalmologist in the past 2 years, 48 (71%) reported a dilated fundus examination during that time. This compares with 28 (43%) reported dilated fundus examinations in the 65 people who had seen an optometrist in the past 2 years. This finding is statistically significant (chi 2 = 10.2, 1 df, p < 0.005). CONCLUSION: These results indicate that nearly half of people with diabetes in Melbourne are not receiving adequate screening or follow up for diabetic retinopathy, despite universal health care.

Keystone media: the Australian and Indigenous affairs

This article conceptualises The Australian as the nation’s ‘keystone media’ on Indigenous affairs.Nielsen’s term ‘keystone media’ captures the critical importance of particular news outlets that play what he terms an outsize role in defining the state and structure of wider media and politicalenvironments. The article analyses the factors at play in The Australian’s sponsorship of a particular political agenda for this complex field of social policy. The argument is illustrated through an examination of Indigenous health coverage from 1988 to 2008, textual analysis of 137 columnswritten by Noel Pearson, and research interviews with key actors in the Indigenous policy realm, including journalists, public servants and Indigenous commentators. Through this examination of its reporting and collaboration with Pearson, we contend The Australian has advanced a range of neoliberal and interventionist policies to government and the public.

Checks and cheques : implementing a population health and recall system to improve coverage of patients with diabetes in a rural general practice

Identification of all diabetic patients in the population is essential if diabetic care is to be effective in achieving the targets of the St Vincent Declaration.¹ The challenge therefore is to establish population based monitoring and control systems by means of state of the art technology in order to achieve quality assurance in the provision of care for patients with diabetes. ^2,3 Disease management receives extensive international support as the most appropriate approach to organising and delivering healthcare for chronic conditions like diabetes.⁴ This approach is achieved through a combination of guidelines for practice, patient education, consultations and follow up using a planned team approach and a strong focus on continuous quality improvement using information technology. ^5,6 The current software (Medical Director) could not easily meet these requirements which led us to adopt a trial of Ferret. In designing this project we used change management⁷ and the plan, do, study, act cycle⁸ illustrated in Diagram 1.

In the shadow of the volcanoes: the impact of intervention on the nutrition and health status of Rwandan refugee children in Zaire two years from the exodus

Objective: To evaluate the public health and nutritional situation of refugee children in Katale camp, Eastern Zaire, after two years of nutritional and health intervention from 1994 to 1996.
Design: Cross-sectional survey using a two-stage cluster sampling method. Anthropometric data were collected from 28 May 1996 to 4 June 1996. Retrospective review of food basket monitoring data over the preceding six months and the United Nations High Commission for Refugees' weekly mortality data was conducted. Measles immunisation coverage data were surveyed simultaneously, using child health records.
Main outcome measures: Nutritional status measured by weight-for-height index (W/H), measles immunisation status, average daily energy content of the general food ration and crude mortality rate.
Setting: Katale refugee camp, Zaire, June 1996.
Analysis: Weight-for-height index and proportion of immunised children were computed using EPINUT, part of EPINFO computer package.
Results: Malnutrition was found to be most prevalent in children aged six to 29 months old (W/H < -2 Z-score and/or oedema: 6.2%; 95% CI: 3.4%, 10.6%), among whom the malnutrition rate was almost double the overall malnutrition prevalence (W/H < -2 Z-score and/or oedema: 3.5% (95% CI: 1.5%, 7.2%). The general food ration, although conforming to the World Food Program minimum standards of adequacy in terms of variety (being composed of cereals, oil, beans, blended cereal and legume mixes and salt), provided only 6240 kJ on average (95% CI: 5040, 7140 kJ) per person per day, thus meeting only 57% to 84% of the minimum energy requirements for an adult, and falling well below the needs for sub groups with higher nutritional requirements such as children, pregnant and breastfeeding women and the sick. Measles immunisation coverage in children nine to 59 months was 88.6%. The crude mortality rate was found to be 0.3 per 10 000 per day. Refugees received 15 litres of clean water per person per day.
Conclusion: Public health interventions in Katale camp 1994 to 1996 had reduced mortality and morbidity rates dramatically. This was not reflected in the malnutrition rates for children under five years, that remained stable after an initial fall despite two years of nutritional intervention. The factors contributed to this were related to an inadequate general food ration (due to food shortages), lack of ability to supplement the diet, (due to economic restrictions that were imposed in the camp) and inequities in the food distribution process (due to food being siphoned off by camp leaders for military purposes).

Why invest in a national public health program for stroke? An example using Australian data to estimate the potential benefits and cost implications

Objectives: Stroke is the world’s second leading cause of death in people aged over 60 years. Approximately 50,000 strokes occur annually in Australia with numbers predicted to increase by about one third over 10-years. Our objectives were to assess the economic implications of a public health program for stroke by: (1) predicting what potential health-gains and cost-offsets could be achieved; and (2) determining the net level of annual investment that would offer value-for-money.

Methods: Lifetime costs and outcomes were calculated for additional cases that would benefit if ‘current practice’ was feasibly improved, estimated for one indicative year using: (i) local epidemiological data, coverage rates and costs; and (ii) pooled effect sizes from systematic reviews.

Interventions: blood pressure lowering; warfarin for atrial fibrillation; increased access to stroke units; intravenous thrombolysis and aspirin for ischemic events; and carotid endarterectomy. Value-for-money threshold: AUD$30,000/DALY recovered.

Results: Improved, prevention and management could prevent about 27,000 (38%) strokes in 2015. In present terms (2004), about 85,000 DALYs and AUD$1.06 billion in lifetime cost-offsets could be recovered. The net level of annual warranted investment was AUD$3.63 billion.

Conclusions: Primary prevention, in particular blood pressure lowering, was most effective. A public health program for stroke
is warranted

Heterogeneity in service delivery and inequity in access are common characteristics of chronic heart failure management programs

Background: The prevalence of heart failure in Australia is similar to that of Europe. In Australia, chronic heart failure management programs (CHF-MPs) have become part of standard care for patients with Chronic Heart Failure (CHF). However, heterogeneity among programs is common which can result in variable patient outcomes.

Method: A national survey was undertaken of 59 post-discharge CHF-MPs identified from within the Australian health care system. Two had ceased operating and one centre declined to participate in the study. A 33-item investigator-developed questionnaire, examining the characteristics and interventions used within each CHF-MP, was sent to the remaining 56 CHF-MPs. A response rate of 100% was achieved.

Results: Our survey revealed a disproportional distribution of CHF-MPs across the Australian continent: the State of Victoria had 3.6 CHF-MPs/million population, New South Wales had 3.7 CHF-MPs/million population, Queensland had 1 program/million population, South Australia had 0.3 CHF-MPs/million population and Western Australia had 1 program/million population.Overall, 8000 postdischarge CHF pts (median: 126; IQR: 26-260) were managed via CHF-MPs. Approximately 40,000 CHF pts are discharged from metropolitan institutions nationally, this represents only 22% of the potential caseload for these cost-effective CHF-MPs. Only 8% of these programs were located within rural regions. The majority of CHF-MPs were located within an acute metropolitan hospital (52%) and 36% were community based (all associated with a hospital). Heterogeneity of CHF-MPs in applied models of care was evident with 75% of CHF-MPs offering CHF outpatient clinics and 77% conducting home visits. Of the programs offering home visits 78% were funded by regional government (p<0.048). There were no nurse-led CHF outpatient clinics. A hybrid approach to CHF-MPs was common with many CHF-MPs comprising an outpatient clinic, home visits and inpatient visits. Various medications were titrated by nurses in 43% of CHF-MPs. In the programs that allowed nurses to titrate medications 79% were located in an acute hospital (p<0.011).

Conclusion: Variability of service availability is of concern within the context of universal coverage. In addition, heterogeneity between programs and the diversity in models of care delivery highlights the inconsistency and questions the quality of health related outcomes. We are currently analysing health outcome data from the 1015 patients managed in these CHF-MPs to describe the relationship between quality of care and health outcomes.

Maternal health in Lao PDR : repositioning the goal posts

This paper reviews attempts made in the Lao People's Democratic Republic (PDR) to achieve Millennium Development Goal (MDG) 5: Improve Maternal Health and its two targets: (1) to reduce by three quarters the maternal mortality ratio and (2) to achieve universal access to reproductive health. It will be shown that significant strides have been made in relation to both the targets, especially in the province of Xayaboury where the contraceptive prevalence rate is the highest and maternal mortality is the lowest in the country. That said, it is unlikely that either target will be realised by 2015 for the nation as a whole. Some of the reasons for this are canvassed such as problems with the existing health infrastructure and its personnel, the cost of health care, the demographic profile and cultural expectations of women of childbearing age, geographic barriers, the absence of communication and transport infrastructure and the influence of international donors on how monies are expended. As discussions now begin to set the framework for the post-MDG compact of the international community to address poverty and well-being, it would be valuable to consider the multiplicity of factors which directly impact maternal and infant mortality rates (such as family planning, age at first birth, access to antenatal care and government expenditure on maternal health care) and explain what causes change, over non-contextualised statistics that simply report changes.

The cost-effectiveness of universal newborn screening for bilateral permanent congenital hearing impairment : systematic review

Objective - Universal newborn hearing screening for bilateral permanent congenital hearing impairment is standard practice in many developed economies, but until there is clear evidence of cost-effectiveness, it remains a controversial use of limited health care resources. We conducted a formal systematic review of studies of newborn hearing screening that considered both costs and outcomes to produce a summary of the available evidence and to determine whether there was a need for further research.

Methods - A search was conducted of medical and nursing databases and gray literature websites by the use of multiple keywords. The titles and abstracts of studies were examined for preliminary inclusion if reference was made to newborn hearing screening, and to both costs and outcomes. Studies of potential relevance were independently assessed by 2 health economists for final inclusion in the review. Studies that met inclusion criteria were appraised by the use of existing guidelines for observational studies, economic evaluations and decision analytic models, and reported in a narrative literature review.

Results - There were 22 distinct observational or modeled evaluations of which only 2 clearly compared universal newborn hearing screening to risk factor screening for bilateral permanent congenital hearing impairment. Of these, the single evaluation that examined long-term costs and outcomes found that universal newborn hearing screening could be cost-saving if early intervention led to a substantial reduction in future treatment costs and productivity losses.

Conclusions - There are only a small number of economic evaluations that have examined the long-term cost-effectiveness of universal newborn hearing screening. This is partly attributable to ongoing uncertainty about the benefits gained from the early detection and treatment of bilateral permanent congenital hearing impairment. There is a clear need for further research on long-term costs and outcomes to establish the cost-effectiveness of universal newborn hearing screening in relation to other approaches to screening, and to establish whether it is a good long term investment.

Preventing mental health problems in children : the families in mind population-based cluster randomised controlled trial.

Background

Externalising and internalising problems affect one in seven school-aged children and are the single strongest predictor of mental health problems into early adolescence. As the burden of mental health problems persists globally, childhood prevention of mental health problems is paramount. Prevention can be offered to all children (universal) or to children at risk of developing mental health problems (targeted). The relative effectiveness and costs of a targeted only versus combined universal and targeted approach are unknown. This study aims to the effectiveness, costs and uptake of two approaches to early childhood prevention of mental health problems ie: a Combined universal-targeted approach, versus a Targeted only approach, in comparison to current primary care services (Usual care).
Design

Three armed, population-level cluster randomised trial (2010-2014) within the universal, well child Maternal Child Health system, attended by more than 80% of families in Victoria, Australia at infant age eight months. Participants: Families of eight month old children from nine participating local government areas. Randomised to one of three groups: Combined, Targeted or Usual care. Intervention: (a) the Combined universal and targeted program where all families are offered the universal Toddlers Without Tears group parenting program followed by the targeted Family Check-Up one-on-one program or (b) the Targeted Family Check-Up program. The Family Check-Up program is only offered to children at risk of behavioural problems. Analysis: Participants will be analysed according to the trial arm to which they were randomised, using logistic and linear regression models to compare primary and secondary outcomes. An economic evaluation (cost consequences analysis) will compare incremental costs to all incremental outcomes from a societal perspective.
Discussion

This trial will inform public health policy by making recommendations about the effectiveness and cost-effectiveness of these early prevention programs. If effective prevention programs can be implemented at the population level, the growing burden of mental health problems could be curbed.