Tuberculosis and health sector reform: experience of integrating tuberculosis services into the district health system in rural South Africa

SETTING: Hlabisa health district, South Africa. OBJECTIVE: To describe the integration of a vertical tuberculosis control programme into an emerging 'horizontal' district health system, within the context of health sector reform. DESIGN: Descriptive account of the process of integration of the programme into the health system. RESULTS: A highly 'vertical' system of delivering tuberculosis treatment (with poor programme outcomes) was converted into a (horizontal' team, integrated within the district health system, that used available resources such as village clinics and community health workers, with improved programme outcomes. CONCLUSIONS: In some settings at least, integration of tuberculosis 'programmes' into the district health system as tuberculosis 'teams' is feasible, and may produce highly cost-effective outcomes.

Parental reactions to infant death: The effects of resources and coping strategies

The aim of this research was to examine, from a stress and coping perspective, the effects of resources (both personal and environmental) and coping strategies on parental reactions to infant death. One hundred and twenty-seven parents (60 fathers, 67 mothers) participated in the study. The predictors of parental distress (background factors, resources, coping methods) were initially assessed at 4-6 weeks post-loss. Parental distress (assessed using a composite measure of psychiatric disturbance, physical symptoms, and perinatal grief) was further assessed at 6 months post-loss and at 15 months postloss. After control for the stability in adjustment across time, there was consistent evidence that higher levels of education were associated with lower levels of parental distress over time. Among mothers, the number of friends in whom mothers had the confidence to confide emerged as a positive predictor of adjustment to infant death. A reliance on problem-focused coping was associated with greater maternal distress at 6 months post-loss, whereas coping by seeking support was associated with less distress at 15 months post-loss. There is no evidence that background factors and resources influenced parental distress through coping.

Lessons from a comprehensive clinical audit of users of psychiatric services who committed suicide

Objective: Characteristics of patients who committed suicide were examined to provide a picture of the treatment they received before death and to determine whether and how the suicides could have been pre vented by the service system. Methods: The unnatural-deaths register was matched to the psychiatric case register in the state of Victoria in Australia to identify suicides by people with a history of public-sector psychiatric service use who committed suicide between July 1, 1989, and June 30, 1994. Data on patient and treatment characteristics were examined by three experienced clinicians, who made judgments about whether the suicide could have been prevented had the service system responded differently. Quantitative and qualitative data were descriptively analyzed. Results: A total of 629 psychiatric patients who had committed suicide were identified. Seventy-two percent of the patients were male, 62 percent were under 40 years old, and 51 percent were unmarried. They had a range of disorders, with the most common being schizophrenia or schizoaffective disorder (36 percent). Sixty-seven percent had previously attempted suicide. A total of 311 patients (49 percent) received care within four weeks of death. Twenty percent of the suicides were considered preventable. Key factors associated with preventability were poor staff-patient relationships, incomplete assessments, poor assessment and treatment of depression and psychological problems, and poor continuity of care. Conclusions: Opportunities exist for the psychiatric service system to alter practices at several levels and thereby reduce patient suicides.

Effect of removing user fees on attendance for curative and preventive primary health care services in rural South Africa

User fees are used to recover costs and discourage unnecessary attendance at primary care clinics in many developing countries. In South Africa, user fees for children aged under 6 yea rs and pregnant women were removed in 1994, and in 1997 all user fees at all primary health care clinics were abolished. The intention of these policy changes was to improve access to health services for previously disadvantaged communities. We investigated the impact of these changes on clinic attendance patterns in Hlabisa health district. Average quarterly new registrations and total attendances for preventive services (antenatal care, immunization, growth monitoring) and curative services (treatment of ailments) at a mobile primary health care unit were studied from 1992 to 1998. Regression analysis was undertaken to assess whether trends were statistically significant. There was a sustained increase in new registrations (P = 0.0001) and total attendances (P = 0.0001)for curative services, and a fall in new registrations (P = 0.01) and total attendances for immunization and growth monitoring (P = 0.0002) over the study period. The upturn in demand for curative services started at the time of the first policy change. The decreases in antenatal registrations (P = 0.07) and attendances (P = 0.09) were not statistically significant The number of new registrations for immunization and growth monitoring increased following the first policy change but declined thereafter. We found no evidence that the second policy change influenced underlying trends. The removal of user fees improved access to curative services but this may have happened at the expense of some preventive services. Governments should remain vigilant about the effects of new health policies in order to ensure that objectives are being met.

Perceived need for mental health care: influences of diagnosis, demography and disability

Background. Recent major epidemiological studies have adopted increasingly multidimensional approaches to assessment. Several of these have included some assessment of perceived need for mental health care. The Australian National Survey of Mental Health and Wellbeing, conducted in 1997, included a particularly detailed examination of this construct, with an instrument with demonstrated reliability and validity. Methods. A clustered probability sample of 10641 Australians responded to the field questionnaire for this survey, including questions on perceived need either where there had been service utilization, or where a disorder was detected by administration of sections of the Composite International Diagnostic Interview. The confidentialized unit record file generated from the survey was analysed for determinants of perceived need. Results. Perceived need is increased in females, in people in the middle years of adulthood, and in those who have affective disorders or co-morbidity. Effects of diagnosis and disability can account for most of the differences in gender specific rates. With correction for these effects through regression, there is less perceived need for social interventions and possibly more for counselling in females; disability is confirmed as strongly positively associated with perceived need, as are the presence of affective disorders or co-morbidity. Conclusions. The findings of this study underscore the imperative for mental health services to be attentive and responsive to consumer perceived need. The substantial majority of people who are significantly disabled by mental health problems are among those who see themselves as having such needs.

Multiresolution spatial databases: Making web-based spatial applications faster

Spatial data has now been used extensively in the Web environment, providing online customized maps and supporting map-based applications. The full potential of Web-based spatial applications, however, has yet to be achieved due to performance issues related to the large sizes and high complexity of spatial data. In this paper, we introduce a multiresolution approach to spatial data management and query processing such that the database server can choose spatial data at the right resolution level for different Web applications. One highly desirable property of the proposed approach is that the server-side processing cost and network traffic can be reduced when the level of resolution required by applications are low. Another advantage is that our approach pushes complex multiresolution structures and algorithms into the spatial database engine. That is, the developer of spatial Web applications needs not to be concerned with such complexity. This paper explains the basic idea, technical feasibility and applications of multiresolution spatial databases.

FOOD, FUEL, FORESTS, AND THE PRICING OF ECOSYSTEM SERVICES

U.S. Department of Energy (DOE), Office of Science[DE-FG02-94ER61937]

Preparation, characterization and catalytic studies of V2O5-SiO2 xerogel composite

In this work, we report the synthesis, characterization and catalytic properties of a vanadium oxide-silicon oxide composite xerogel prepared by a soft chemistry approach. In order to obtain such material, we submitted a vanadium pentoxide gel previously synthesized via protonation of metavanadate species to an ""in situ"" progressive polycondensation into silica gel. The material has been characterized by X-ray diffraction, infrared spectroscopy, thermogravimetric analysis and scanning electron microscopy. Further, the catalytic activity of this material was evaluated for the epoxidation of styrene and cyclooctene using iodosylbenzene, hydrogen peroxide and m-chloroperbenzoic acid as the oxidizing agent.

Compensation for obesity-induced insulin resistance in dogs: Causal web analysis of the associations of leptin and GLP-1.

Obesity affects aspects of glucose homeostasis such as insulin secretion and insulin sensitivity. Hormones secreted by adipocytes like leptin mediate the metabolic consequences of obesity. Incretin hormones like glucagon-like peptide-1 (GLP-1) increase insulin secretion in response to changes in blood glucose concentration and have been proposed to regulate insulin secretion in fasting, overweight dogs. The aim of this study was to examine hormonal mechanisms by which adiposity alters glucose homeostasis, plasma insulin concentration, and insulin sensitivity in spontaneously overweight dogs.

The structure of a novel insecticidal neurotoxin, omega-atracotoxin-HV1, from the venom of an Australian funnel web spider

A family of potent insecticidal toxins has recently been isolated from the venom of Australian funnel web spiders. Among these is the 37-residue peptide omega-atracotoxin-HV1 (omega-ACTX-HV1) from Hadronyche versuta. We have chemically synthesized and folded omega-ACTX-HV1, shown that it is neurotoxic, ascertained its disulphide bonding pattern, and determined its three-dimensional solution structure using NMR spectroscopy. The structure consists of a solvent-accessible beta-hairpin protruding from a disulphide-bonded globular core comprising four beta-turns. The three intramolecular disulphide bonds form a cystine knot motif similar to that seen in several other neurotoxic peptides. Despite limited sequence identity, omega-ACTX-HV1 displays significant structural homology with the omega-agatoxins and omega-conotoxins, both of which are vertebrate calcium channel antagonists; however, in contrast with these toxins, we show that omega-ACTX-HV1 inhibits insect, but not mammalian, voltage-gated calcium channel currents.

Accuracy of store-and-forward diagnosis in leproy

Telemedicine might increase the speed of diagnosis for leprosy and reduce the development of disabilities. We compared the accuracy of diagnosis made by telemedicine with that made by in-person examination. The cases were patients with suspected leprosy at eight public health clinics in outlying areas of the city of Sao Paulo. The case history and clinical examination data, and at least two clinical images for each patient, were stored in a web-based system developed for teledermatology. After the examination in the public clinic, patients then attended a teaching hospital for an in-person examination. The benchmark was the clinical examination of two dermatologists at the university hospital. From August 2005 to April 2006, 142 suspected cases of leprosy were forwarded to the website by the doctors at the clinics. Of these, 36 cases were excluded. There was overall agreement in the diagnosis of leprosy in 74% of the 106 remaining cases. The sensitivity was 78% and the specificity was 31%. Although the specificity was low, the study suggests that telemedicine may be a useful low-cost method for obtaining second opinions in programmes to control leprosy.

Caring for someone with dementia in a rural town .2. Services

Dementia care in rural areas is in need of attention from researchers, planners and policy makers. Family carers in these areas face some significant challenges, in terms of managing the care where support services are often unavailable or inaccessible. This paper reports on a qualitative study in which a group of rural based carers participated in a focus group and interviews. Through this process, the carers' perceptions of support services were explored. Content analysis of the data revealed that, despite a number of supportive aspects of rural life, these carers felt in need of more services, a finding supported by current literature.