The authors of this study set out to assess the prevalence of cardiovascular (CV) risk factors in Seychelles, a middle-income African country, and compare the cost-effectiveness of single-risk-factor management with management based on total CV risk. CV risk factor prevalence and a CV risk prediction chart for Africa were used to estimate the 10-year risk of suffering a fatal or non-fatal CV event among individuals aged 40–64 years. These figures were used to compare single-risk-factor management with total risk management in terms of the number of people requiring treatment to avert one CV event and the number of events potentially averted over 10 years. With single-risk-factor management, 60% of adults would need to be treated and 157 cardiovascular events per 100,000 population would be averted per year, as opposed to 5% of adults and 92 events with total CV risk management. Management based on high total CV risk optimizes the balance between the number requiring treatment and the number of CV events averted. In conclusion, total CV risk management is much more cost-effective than single-risk-factor management. These findings are relevant for all countries, but especially for those economically and demographically similar to Seychelles.
Equitable health services
This study investigated the extent and predictors of condom use and condom refusal in the Free State province in South Africa. Through a household survey, 5,837 adults were interviewed. Eighty-three per cent of the respondents had used condoms before, of which 38% always used them, 61% used them during the last sexual intercourse and 9% had refused in the past to use them. The analysis indicated that the strongest predictor of condom use was its perceived need, followed by 'knowledge of correct use of condom' and condom availability, as well as being young in age, single and having a higher education. The strongest predictor of condom refusal was shame associated with condoms, as well as lacking knowledge about the use of condoms. The authors conclude that further improvement in correct and consistent use of condoms will require targeted interventions. In addition to existing social marketing campaigns, tailored approaches should focus on establishing the perceived need for condom-use and improving skills for correct use. They should also incorporate interventions to reduce the shame associated with condoms and individual counselling of those likely to refuse condoms.
In this study, researchers examined the factors associated with use of nets owned in Ghana. The data was derived from an August 2008 survey in Ghana of households with a pregnant woman or a guardian of a child under five, conducted during the rainy season. A total of 1,796 households were included, which generated a sample of 1,852 mosquito nets. The final multivariate model consisted of ten variables statistically associated with whether or not the net was used the prior night: rural location, lower socio-economic status, not using coils for mosquito control, fewer nets in the household, newer nets and those in better condition, light blue colour, higher level of education of the guardian of the child under five, knowing that mosquitoes transmit malaria, and paying for the net instead of obtaining it free of charge. The results of this study suggest that net use would increase in Ghana if coloured nets were made available in mass distributions as well as in the commercial market; if programmes emphasise that malaria is caused only by night-biting mosquitoes, and that nets protect against mosquitoes better than coils and need to be used even if coils are burning; if donated nets are replaced more frequently so that households have nets that are in good condition; and if there were support for the commercial market so that those who can afford to purchase a net and want to choose their own nets can do so.
Early identification of tuberculosis (TB) treatment failure using cost effective means is urgently needed in developing nations. The authors of this study set out to describe affordable predictors of TB treatment failure in an African setting by determining the predictors of treatment failure among patients with sputum smear-positive pulmonary TB clinic at Mulago Hospital in Kampala, Uganda. This was an unmatched case control study where fifty patients with a diagnosis of TB treatment failure (cases) and 100 patients declared cured after completing anti-TB treatment (controls) were recruited into the study. Cases were compared with controls to determine predictors of treatment failure. Significant predictors of treatment failure in this study included a positive sputum smear at two months of TB treatment and poor adherence to anti-TB treatment. The authors found that positive sputum smear at two months of TB treatment and poor adherence to anti TB treatment were reliable and affordable predictors of TB treatment failure. These predictors may be used in resource-limited settings for early recognition of those at risk and early intervention, they conclude.
The aim of this paper was to describe the pre-operative surgical case mix among patients undergoing cataract extraction and explore associations between case mix, country level of development (as measured by the Human Development Index, or HDI) and cataract surgery rates (CSRs). Ophthalmologists at 112 eye hospitals (54% of them non-governmental) in 50 countries provided data on 11,048 cataract procedures over nine months in 2008. Patients whose visual acuity (VA) before surgery was < 6/60 in the better eye comprised 47% of the total case mix in poorly developed countries and 1% in developed countries. Overall, 72% of the eyes undergoing surgery had a VA < 6/60. Very low VA before cataract surgery was strongly associated with poor development at the country level and inversely associated with national CSRs. The researchers conclude that the proportion of patients with very poor preoperative VA is a simple indicator that can be easily measured periodically to monitor progress in ophthalmological services. Additionally, the internet can be an effective tool for developing and supporting an ophthalmological research network capable of providing a global snapshot of service activity, particularly in developing countries.
This study assessed the preparedness of the health care facilities for the Ebola (EVD) outbreak response in Kasese and Rubirizi districts in western Uganda. It involved interviews with 189 health care workers and visits to 22 health facilities. Twelve out of the 22 of the health facilities did not have a line budget to respond to EVD and the majority of the facilities did not have case definition books, rapid response teams and/or committees, burial teams, and simulation drills. There were no personal protective equipment that could be used within 8 h in case of an EVD outbreak in fourteen of the 22 health facilities. All facilities did not have viral haemorrhagic fever incident management centers, isolation units, guidelines for burial, and one-meter distance between a health care worker and a patient during triage. The authors recommend proactively tracking the level of preparedness to inform strategies for building capacity of health centers in terms of infrastructure, logistics and improving knowledge of health care workers.
The objectives of this study were to quantify secular trends in health facility delivery and to identify factors that affect the uptake of intrapartum healthcare services amongst women living in rural villages in Bugesera District, Eastern Province, Rwanda. Using census data, researchers selected 30 villages for community-based, cross-sectional surveys of women aged 18-50 who had given birth in the previous three years. Their analysis of 3,106 lifetime deliveries from 859 respondents showed a sharp increase in the percentage of health facility deliveries in recent years. The strongest correlates of facility-based delivery in Bugesera District include previous delivery at a health facility, possession of health insurance, greater financial autonomy, more recent interactions with the health system, and proximity to a health centre.
The authors of this study prospectively assessed resistance to second-line anti-tuberculosis drugs in eight countries, including South Africa. From 1 January 2005 to 31 December 2008, they enrolled consecutive adults with locally confirmed pulmonary multi-drug-resistant (MDR) tuberculosis at the start of second-line treatment. Among 1,278 patients, 43.7% showed resistance to at least one second-line drug, 20% to at least one second-line injectable drug and 12.9% to at least one fluoroquinolone. A total of 6.7% of patients had extremely drug-resistant (XDR) tuberculosis. Previous treatment with second-line drugs was consistently the strongest risk factor for resistance to these drugs, which increased the risk of XDR tuberculosis by more than four times. Fluoroquinolone resistance and XDR tuberculosis were more frequent in women than in men. Unemployment, alcohol abuse and smoking were associated with resistance to second-line injectable drugs across countries. Other risk factors differed between drugs and countries. The authors recommend that representative drug-susceptibility results should guide in-country policies for laboratory capacity and diagnostic strategies.
This research asks whether a cervical cancer prevention programme in South Africa that includes an HPV vaccine is more cost-effective than the current strategy of screening alone. It found that, while a combination of vaccination and screening at the current vaccine price is more costly than screening alone, it is a cost-effective strategy for preventing cervical cancer. The main cost driver is the vaccine cost. If the vaccine price is reduced, vaccination followed by screening might be a very affordable policy option. The vaccine has the potential to reduce the incidence of HPV-related diseases, and to reduce the cost of treating cervical cancer. This requires a well-functioning screening programme aimed at secondary prevention of cervical cancer as the HPV vaccine does not eliminate, but rather reduces the risk of cervical cancer. In South Africa, screening coverage is very low (well below 50%) and adherence to treatment of pre-cancerous and cancerous lesions is also less than 100%, thus having another preventative measure could be desirable. Approaches for reducing the cost of introducing the vaccine (which should be publicly funded) include accessing international funding mechanisms, such as the United Nations Children’s Fund (UNICEF), using public-private partnerships and getting commitment from pharmaceutical companies to reduce prices.
In many low- and middle-income countries, the challenges of scaling up successful localized projects to achieve national coverage are well recognized. The wide success of efforts to scale up interventions to prevent and control human immunodeficiency virus (HIV) infection mean that it is now managed as a chronic condition. Lessons from the HIV experience may thus be transferable to the rollout and scale-up of effective interventions for noncommunicable diseases in low- and middle-income countries. WHO’s best buys for reducing noncommunicable diseases in low-resource settings suggest several such interventions. They include measures to improve tobacco control, increase public awareness of the health benefits of physical activity, multidrug therapy for people at high risk of cardiovascular disease and the screening and treatment of cervical cancer. While there is much to learn from the HIV experience, noncommunicable diseases have peculiarities that may limit the transferability of learning or require significant adaptation of such learning, while there are also issues to address in transfering learning on noncommunicable disease prevention and control between high-income and low- and middle-income countries. The authors call for the development of research and practice platforms that allow for progressive and systematic accumulation and sharing of field learning from scale-up efforts of HIV interventions and from the scale-up of noncommunicable disease interventions between settings