Geneva Health Forum Archive

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Mental Health and Young People: International Perspectives on Growing Challenges

Author(s): Anne Meynard1, Dagmar Haller1, Daliborka Pejic2, Suzanne Ehrensberger3, Patana Mulisanze3, Saskia von Overbeck4
Affiliation(s): 1Hôpitaux universitaires Genève, Departement de l’enfant et de l’adolescent et Dpt de médecine communautaire, de premier recours et des urgences, 2Fondacija fami, Doboj, Bosnia & Herzegovina, 3Association Santé Mentale: Suisse Rwanda, 4Service de psychiatrie de l’enfant et de l’adolescentDepartement de l’enfant et de l’adolescent Hôpitaux Universitaires de Genève
1st country of focus: Bosnia and Herzegovina, Switzerland, Australia
Relevant to the conference theme: Vulnerable groups
Summary (max 100 words): There is urgent need of innovative and multisectoral interventions to address mental health issues in young people. Lack of trained professionals or adapted services, impact of socioeconomic factors on mental health are some of the challenges faced by many countries around the world. Interprofessional collaboration, community programs, International partnerships and web-based interventions can maximize the use and exchange of expertise among professionals, young people and their families.
What challenges does your project address and why is it of importance?: The presentation will present short aspects of two collaboration projects (Rwanda and Bosnia and Herzegovina) and experience in Geneva with vulnerable youth, questioning innovative ways of addressing mental health issues with young people and international collaboration. About Bosnia &Herzegovina: Great societal changes and turmoil, such as postwar trauma, unemployment and poverty, have undoubtedly negative effects on the occurrence of risk behavior and health of youth in BiH. About 50% of the young people have lost some family member or a close relative, and around 16% of people suffer from PTSD. UNPFA data show that around 50% of young people in Sarajevo and around 60% in Banja Luka do not use condom during sexual intercourses. Around 30% of young people are regular smokers, 21% frequently consume alcohol; 5.8% of boys and 6,8 of girls have experienced drugs. UNFPA data show that around 50% of young people in Sarajevo, i.e. around 60% in Banja Luka, do not use condom during sexual intercourses. In spite of significant achievements (psychiatric services and community mental health), existing mental health services are still unable to respond to the multiple and growing needs of the population, and in particular young people. Social stigma, segregation and isolation of people with mental health problems, are main barriers to treatment and reintegration of the people with mental health problems. About Rwanda: In the aftermath of the genocide, a significant number of the Rwandan population is traumatised and needs help. The country has very few psychiatrists to take care of the patients and the task is not easy for them because they have to face a huge demand. Moreover, physicians in general have practically no training in mental health. In view of the current state of affairs that is high demand of patients to take care of alongside scarce human and logistical resources, group therapy is deemed to be a very good way to treat people. This form of care can be used in different age ranges from children to adults. Since there is a shortage of skilled and trained people in psychiatry, it is of paramount importance to train the available health workers in this kind of care. This year we start to teach our colleagues with the Child Psychiatry, again this was very useful.
How have you addressed these challenges? Do you see a solution?: About Bosnia &Herzegovina: An established network of family medicine teams is serving as the base to support the development of new activities in various fields, including mental health. According to the BiH Strategic Health Care Reform plan, Family Medicine has been assigned as the primary health care provider also for adolescents. The projects focus has been, therefore, on strengthening family medicine activities in the field of working with youth. Training provided FM teams with the basic knowledge on developmental issues, epidemiological data, communication skills with young people and their families, use of screening tools (HEADSSS), confidentiality and youth-friendly principles. Improvement of multidisciplinary and multi-sectoral collaboration started by including the participants from other departments/institutions/organizations in the training, thus initiating the creation of a network of health and non-health service providers in the municipality (CBR professionals, youth-friendly center staff, social workers, school pedagogues, young people, NGOs, VCCT center. etc.). The network is to be strengthened through implementation of practical tasks, development of procedure/protocols and actions plans, network meeting, etc. Promotional activities, such as round table public discussion and distribution of network leaflets, aim to better inform the community and young people, about the available help. Development of practical tools, such as translation of the WHO Adolescent Job Aids, will be of valuable assistance in everyday work with youth.

About Rwanda: One way to address these challenges is to train the Rwandan colleagues in these methods of treatment. We have been working with them since 1996 and they are currently becoming little by little familiar with the basic notions of psychiatry. After years of collaboration, we can now start to introduce them to different aspects of this specialization. A few weeks ago the Minister of Health talked about launching the training phase of colleagues assisted with partners. We hope to participate to this coming form of collaboration. As long as we do not foresee in the near future any university training in psychiatry, I do not think we there will be any tangible solution to these challenges.
How do you know whether you have made a difference?: About Bosnia &Herzegovina: The training itself showed how important it was for the participants to have the opportunity to “hear each other”, learn more about already available services in the community and together start improving work with and for youth and develop specific services for young people adapted to the local context of each municipality.

About Rwanda:We examined the first sessions we conducted with health workers and noticed that they have started to integrate or internalize some theoretical aspects. In addition, these health workers are more receptive to new concepts. We also observed that our colleagues are becoming more skilled and comfortable in their work. They also are more interested in the training, we have new demands.
Have you or the project mobilized others and if so, who, why and how?: About Rwanda: Since the HUG has stopped their funding, we only have the membership fee from our joint mental health Association (Association Santé Mentale: Suisse Rwanda). The Association “Saturnales 2010” gave us some funds to run and conduct a training in group therapy. As a result, there is a positive feedback from Rwanda and we have begun the process of sensitizing the importance of this project and calling for partners in different kinds of forum such as this congress
When your donor funding runs out how will your idea continue to live?: About Bosnia &Herzegovina: By relying on existing standards and strategies, formalizing mutual collaboration and work with youth with protocols and procedures, improving knowledge and skills with training and practical assistance in their implementation, building a pool of local youth health experts, and creating a network of youth service providers, there are reasonable chances that the changes made will continue to live and grow.

About Rwanda: Since we are training doctors, nurses in the country, our goal is that the latter will take over the work we have started and train others when we complete our training activities.

New Educational Programme for Patients with Epilepsy at Geneva University Hospital: Switzerland

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Author(s): Anne-Chantal Héritier Barras1, Anne-Laure Hariel Spinelli1
Affiliation(s): 1Neurology Service, Geneva University Hospitals
Name your project or intiative: New educational programme for patients with epilepsy at Geneva University Hospital
1st country of focus: Switzerland
Relevant to the conference theme: New roles and responsibilities of health personnel
Summary: Even in countries with easy access to medication, patients with epilepsy continue to suffer from psycho-social difficulties often underestimated by health caregivers. An educational programme focused on proper needs of patients is proposed. A comprehensive interview first explores the patients' needs in domains such as comprehension of the disease, emotions and impact on daily social life. Following education sessions a second individual interview with patients was held to evaluate the personal benefit of this approach. Each health caregiver concerned with epileptic patients should be trained in order to systematically include therapeutic education in the care processes.
What challenges does your project address and why is it of importance?: Epilepsy is a chronic neurological condition affecting more than 50 million people worldwide. Medication works well with about 75% of patients. However, the misconceptions, prejudice and subsequent stigma often encountered by patients with epilepsy lead to discrimination, social isolation and personal denial of the disease. Even in developed countries with easy access to antiepileptic drugs and highly technological diagnostic tools, the patients and their families continue to suffer from the physical, psychological, social and economic consequences of epilepsy. The physicians' preoccupation with seizure control and diagnostic processes often overshadows other concerns. A local qualitative study in 2008 explored the educational needs of patients living with epilepsy and how the needs of the patients were perceived by their health caregivers. In comparison with patients, the health caregivers underestimate the difficulties of social adaptations, the direct effect of the seizures and the emotional impact on the patient. In contrast, the concerns of the health professionals reflect their own preoccupations: apprehension in relation to the treatment and comprehension of aetiology. To be effective, a therapeutic educational program must focus on the real needs of the patients and not only on needs perceived by the health caregivers.
How have you addressed these challenges? Do you see a solution?: An educational approach to patients is proposed, focused on their proper needs in order to acquire the necessary competences to live better with epilepsy. The programme is the following. A) An initial comprehensive face-to-face interview between the patient and a health caregiver (nurse or medical doctor) explores the needs of the patient in the four different domains identified in the study mentioned above: 1. Comprehension: “What do I understand about my situation?”2. Emotions: “What do I feel about that?”3. Impact of the disease on the patient: “How does my condition change my daily life?”4. Impact of the disease on the patient’s social life: “How does my condition change my relationship with others?”B) After this first interview, the patient is invited to follow either individual sessions, if the psychological impact predominates, or group sessions, if the social difficulties are prominent. C) In the group sessions, several topics are explored, according to the themes emerging from the study mentioned above:- my seizure: symptoms, localisation in the brain, facilitating factors- management of my seizure: what to do, what to say and to whom- management of my treatment: my advantages and disadvantages to take medication- my specific living conditions: driving licence, applying for a job, pregnancy, travelling, D) Patients benefit from a second individual interview to remind them of the different topics reviewed earlier. The discussion is then continued with the patient's private concerns and difficulties. A personal project is outlined with small objectives in order to become a reality in a near future.
How do you know whether you have made a difference?: An indication of knowing whether we have made a difference is by listening to the patients. During the first face-to-face interview, patients recounted the following:- « If we don’t speak about how we live, the caregivers, the ambulance drivers, the neurologists… they will all never know how we live… So, they won’t understand our daily life. »- « The way a physician learns, the training he received, it is : here is a symptom. Our daily life, our social life: they don’t see them at all. »- « For us, our life isn’t only how many seizures we have and what kind of seizures we have. »And at the second face-to-face interview, we can hear:- « I had the distinct feeling that we could say what we were feeling, that you cared about that, and that it was possible to go further in accordance with how we were living… »- « So, it gave me the impression of being understood, heard. »- « Effectively, I think that to have the opportunity to speak about different concerns, to be able to say things, as well organized as it was : we could express ourselves, listen to each other, unveil our selves, permit to meet each other;  it created a bond, maybe more difficult to create without that. »- « We checked the global situation; I know I have a resource here and that’s great. »- « It helps us in our daily life. »At the moment, we are working on constructing  evaluations, especially auto-evaluations, with an emphasis on patient autonomy. We will evaluate if educational objectives have been reached and if the patient has developed new competences. We also assess the patient’s satisfaction.
Have you or the project mobilized others and if so, who, why and how?: This programme is focused upon those patients who attended educational sessions. The role of patients changed during the process. Passive patients became active partners of health care. The patients’ verbatim (cf. 5.) shows a better comprehension of their own disease, a sharing of life experiences with people in a similar situation and enhanced self-esteem. In parallel, health caregivers are also were affected by the process. They modified their medical practice by considering patients’ preoccupations rather than focusing soley on diagnosis and this was achieved by shared decision-making with the patient and by recognising the patient-health caregiver relationship as a partnership.
When your donor funding runs out how will your idea continue to live?: We do not have specific funding for our educational programme. The awareness and mobilization of the entire medical team taking care of epileptic patients is in progress. Once the medical team is persuaded of the validity of our approach, we hope that education will be included in the health processes and system. If so, the durability of our process will be assured.


Steep Ramp Test: An Efficient Tool to Develop a Pulmonary Rehabilitation Program in the Absence of a Cardio Pulmonary Exercise Test

Project/Initiative Outline:

Author(s): Sandra Da Silva1, Chetna Bhatia1
Affiliation(s) 1Geneva University Hospitals, Geneva, Switzerland
Name your project or intiative Steep Ramp Test: An efficient tool to develop a pulmonary rehabilitation program in the absence of a cardio pulmonary exercise test (CPET)
1st country of focus Switzerland
Relevant to the conference theme Non-communicable chronic diseases;
Summary The Cardio Pulmonary Exercise Testing is a gold standard for the prescription of exercise in a pulmonary rehabilitation program for COPD patients. However, this test is expensive and time consuming and requires sophisticated equipment and the presence of a doctor with elaborate interpretation skills. Exercise prescription for a pulmonary rehabilitation program is essentially done by physiotherapists who do not necessarily have access to the above test. The Steep Ramp Test can be a solution when the CPET is not accessible to the physiotherapists. This was the primary reason for us to develop and create a simple, cost-effective, easily interpretable and reproducible test for our pulmonary rehabilitation program.
Background Meyer & al used the test in 1997 for chronic heart failure patients for the first time followed by De Backer in 2007 and Puhan in 2006 and 2008 for cancer and respiratory insufficiency patients respectively. De Backer demonstrated that the steep ramp test was a valid, practical and secure test when compared with a sub maximal test and CPET to prescribe and elaborate a rehabilitation program for the cancer patients. In our institution all patients inscribed in the pulmonary rehabilitation program do not have a CPET which inspired us to look for a test that can be used to evaluate the maximum short exercise capacity. The test can be performed without the presence of a doctor, can be repeated at regular intervals to adjust the exercise intensity and requires very few means (cycle, oxymeter, Borg scale) making it very cost effective. In our 4 years of experience with this test we found that the COPD patients are able to perform the test without much discomfort as it is of short duration. As numerous COPD patients develop a chronic heart failure, the fact that it was already tested on the cardiac patients makes the test a very safe manner of testing our patients.
Objectives To evaluate if the Steep Ramp Test can be used as an alternatve tool to evaluate exercise intensity in the absence of CPET.
Design: A retrospective study in which the steep ramp test was used to evaluate exercise intensity in a pulmonary rehabilitation program of 3 months. The test was performed along with the six minutes walking test and MRF-28 at the start, at six weeks and end of the program. Participants: 21 patients (8 male, 13 female) suffering from chronic respiratory disease. Mean age +/- 69.19 years, SD (+/-9.5). Setting: University Hospital Geneva Intervention: A 3 month pulmonary rehabilitation program, twice a week including interval training, strength training and patient education, session duration 90 minutes. The patients performed the Steep Ramp Test which was used to evaluate the exercise intensity for the interval training on the ergometer.
Results There was significant improvement in the workload on ergometer (p=0.0001), the distance and the Borg Scale during the 6 minutes walking test (p=0.0001) and in the respiratory health section of the MRF-28 questionnaire,(p=0.001).
Conclusion Steep ramp test is an effective, low cost, practical, easily reproducible test that can be used to construct a pulmonary rehabilitation program in the absence of a CPET. The test needs to be used in conjunction with the six minutes walking test to evaluate the oxygen need.

Geographic epidemiology of death from cardiovascular disease in cities of Kerman province, Iran

Author(s): Seyed Ziae Tabatabaei1, Mohsen Rezaeian2, Arash Dehdari Nejad2
Affiliation(s): 1University Putra Malaysia, Malaysia,2Faculty of Medicine, Rafsanjan University of Medical Sciences, Iran
1st country of focus: Iran
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): The present study focus on drawing maps of geographical distribution of the rate of death from cardiovascular diseases in Kerman province (14 cities) between the years 2003-2004 and as a whole, deals with both male and female.
Background (max 200 words): Cardiovascular disease is the main cause of mortality in the world and is estimated to be the main cause of death in the world by 2020. World Health Organization (WHO) has predicted that 25 per cent of healthy life years will be globally lost due to cardiovascular diseases by 2020. Developing countries are more likely to be influenced by such increase. The prevalence of cardiovascular diseases, especially coronary heart disease, is seriously increasing in Iran. The purpose of this study is to provide geographic distribution maps of death rate of cardiovascular disease in the cities of Kerman province in 2003-2004.
Objectives (max 100 words): The purpose of this study is to provide geographic distribution maps of death rate of cardiovascular disease in the cities of Kerman province in 2003-2004.
Methodology (max 400 words): In this descriptive study, the mortality statistics of all cases registered in Kerman Province were collected. Statistics collected were used for the calculation of mortality rate of death from cardiovascular disease and mapping of geographic distribution. For classifying the data and illustrating them in geographical distribution maps, classifying methods based on equal intervals were applied.
Results (max 400 words): The overall mortality rate of cardiovascular disease in the northern cities of the province is more than the southern cities in the province. The observed pattern is same for the whole population and also for men and women separately.
Conclusion (max 400 words): The pattern observed was probably due to poor diet, lack of mobility and smoking which seem to be more common in northern cities of the province than in the southern cities. Therefore, with proper interventions in society risk factors can either be completely destroyed or decreased.

School Based Intervention to Prevent and Manage Obesity: Tunisia

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Author(s): Jihene Maatoug Maaloul1, Imed Harrabi1, Mylene Belkacem1, Sonia Hmad1, Hassen Ghannem1
Affiliation(s): 1Department of Epidemiology, University Hospital Farhat Hached, Sousse Tunisia
1st country of focus: Tunisia
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): This paper presents the results of a pre assessment study aimed at studying the prevalence of obesity and overweight among two randomized samples
of schoolchildren aged 11 to 16 years old who were enrolled in a school based intervention to prevent and manage obesity in the region of Sousse, Tunisia.
Background (max 200 words): The prevalence of childhood obesity has increased worldwide and in Tunisia we are facing an epidemiological transition.
Objectives (max 100 words): The objective of this research was to study the prevalence of obesity and overweight in a population of school children, and to propose a school
based intervention to prevent and manage obesity in the region of Sousse, Tunisia.
Methodology (max 400 words): This was a quasi experimental design with school based intervention. The intervention group was located in Sousse Jawhara and Sousse Riadh and the
control group was located in the region of Msaken. Pre assessment was done with a randomized sample in each group to evaluate the prevalence of obesity in the school year 2009/2010. It concerned schoolchildren aged 11 to 16 years old. The total number of participants was 4003 with 1929 and 2074 respectively in intervention and control groups. The intervention began in the school year 2010/2011 and will last three years. We used a self administered questionnaire to collect data about socio-demographic characteristics, eating and sedentary habits. We also took weight, height and waist circumference of selected schoolchildren. The intervention program began in school year 2010/2011 and will last three years. It consists of educative sessions on healthy diet and physical activity. It also consists of sensitization days animated byschoolchildren leaders formed by the project team.
Results (max 400 words): The proportion of boys was 50.2% and 46.5% respectively in intervention and control groups. The mean age was 13.24 ±1.26 and 13.48 ± 1.30 in each
group. The proportion of schoolchildren who consume vegetables daily was respectively 28.4% and 40.3% in the intervention and control groups. Likewise, the proportion of fruits consumption was 55.8% and 57.6%. The proportion of schoolchildren who do recommended level of physical activity was 14.7% and 9.5% respectively in intervention and control groups. In the intervention group, the proportion of overweight and obesity was respectively 20.6% and 7%. In the control group, the proportion of overweight and obesity was respectively 15.5% and 4.5%.
Conclusion (max 400 words): Intervention in schools is important to prevent and manage obesity among adolescents.

Spatial Distribution and Dependence of Body Mass Index: Geneva, Switzerland

Project/Initiative Outline:

Author(s): Idris Guessous1, Nicola Cantoreggi2, Stéphane Joost3
Affiliation(s) 1Hôpitaux Universitaires de Genève, Geneva, Switzerland.  2University of Geneva, Geneva, Switzerland. 3École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland.
Name your project or intiative Spatial distribution and dependence of body mass index in the Canton of Geneva, Switzerland
1st country of focus Switzerland
Relevant to the conference theme Non-communicable chronic diseases; Health information and Technologies
Summary The investigators used GIS programs to spatially locate sample participants and assess spatial distribution and dependence of overweight, obesity and body mass index.
Background Urban health (UH) is an emerging field, which explores the effect of urban environment and urbanization on health. Evidence suggests that urban environment can either positively influence health behaviors or be a health stressor. One key approach in UH is the use georeferenced data and geographic information system (GIS). Mapping disease prevalence and trends provide insight into disease mechanisms and etiologies. An important limitation of GIS is that data sets have likely been collected separately by different agencies, often over different time periods. The Canton of Geneva deviates from this limitation as it has been collecting geographic and health-related information continuously since 1998 through the Unit of Population Epidemiology (UEP) of the Geneva University Hospitals and its Bus Santé study.
Objectives Our aims were 1) to explore the spatial distribution of body mass index (BMI) in the Canton of Geneva, 2) to explore the evolution of spatial distribution of BMI between 2001 and 2009 in the Canton of Geneva, and 3) to measure the level of BMI spatial dependence in the Canton of Geneva
We used data from the Bus Santé study. The Bus Santé study is an ongoing, community-based study designed to monitor chronic disease risk factors continuously in the Canton of Geneva, Switzerland. Each randomly selcted participant receives several self-administered, standardized questionnaires covering the risk factors for the major lifestyle chronic diseases, sociodemographic characteristics, educational and occupational histories, as well as reproductive history for women. Participants’ addresses are systematically abstracted, verified, and updated. In addition, participants receive validated questionnaires on Diet (with Energy intake kcal/day calculation) and Physical activity (with MET calulation). Each participant undergoes a physical examination and blood collection in one of the three UEP clinic stations. Spatial information already collected (with the postal address as georeference) or available from GIS databases (communes, parks, roads provided by the Système d’Information du Territoire Genevois (SITG) (e.g. traffic, trees density), the Office Cantonal de la Statistique (OCSTAT), and MicroGIS were considered as chronic cardiovascular exposures or covariates. We used information collected by the “Bus Santé” study, which included >10,000 participants over a 12-year period. We measured the level of spatial dependence of different investigated cardiovascular risk factors, as well as the one of integrated indices like the BMI. Spatial dependence means that we measured how similar were the different values of the different health variables under study for a set of randomly spatially distributed individuals (Bus santé data), and within a rigorously defined neighborhood. Measuring spatial autocorrelation permits a) to quantify the spatial regularity of a given phenomenon on a territory, and b) to determine the range of spatial dependence of this phenomenon on the same area. Autocorrelation can be quantified either globally over a whole territory or locally within the same territory. The opportunity to locally measure spatial dependence is of high interest in our case as it makes it possible to identify specific city districts (“quartiers”) confronted to particular urban configurations, exposed to certain environmental conditions (e.g. air pollution, noise pollution), or meeting precise socio-economic criteria for a specific response in cardiovascular variables. The use of Local Indicators of Spatial Association (LISA) allow for the decomposition of global indicators into the contribution of each observation (an observation being any georeferenced individual participating to the Bus santé action). We used LISA a) as indicators of local pockets of nonstationarity (high/low risk “hot spots” for particular cardiovascular variables) or b) to assess the influence of individual or regional locations on the magnitude of the global statistic to identify outliers
Results Combining health-related data from the Bus Santé study and GIS, the investigators reported the geographic prevalence of overweight and obesity. Map 1 shows the 2001-2009 geographic distribution of overweight (surcharge) or obesity (obésité) prevalences in the Canton of Geneva. Several regions (communes) at high risk appeared clearly on the map with highest prevalences encountered on the right side of Lake of Geneva. Map 2 shows the evolution of the distribution of overweight prevalences in the Canton of Geneva between 2001-2004 and 2005-2009. This map highlights the progression of the burden of overweight and highlights regions that suffer the most from it. The investigators detected significant spatial dependence with respect to BMI (Map not shown). This result clearly indicate that BMI levels are not distributed at random in the Canton of Geneva. Performing preliminary exploratory analyses on blood pressure, investigators have also identified cluster of individuals with higher blood pressure than the average.
Conclusion Our work has both public health and scientific importance. Indeed, this study presents a unique opportunity i) to determine spatial distribution trends of cardiovascular risk factors and ii) to further define the importance of the urban environment on health. Measuring the urban health burden is key since it can guide more effective strategies of housing and urban development (e.g., sidewalks, transportation), which could ultimately promote healthier behaviours. Based on results from similar source of urban health data, movements to promote health in cities have been established (e.g, Healthy Cities, an international project sponsord by the World Health Organization). Outcomes demonstrating associations between urban environment and population’s health status is an important tool to make land planning policies more “health-friendly”. For example, neighborhoods with high walkability mitigate the risk of hypertension at the community level and promotion of neighborhood walkability could play a significant role in improving population health and reducing CVD risk. Currently, little research has been conducted in Switzerland. The main reason is the difficulty to access to robust health data which have a valid link to location. In addition, geographic information on urban environment is generally sub-optimal. An ideal situation is encountered in the Canton of Geneva which has collected more than 12-years of robust population health information, and has extensive public free information on the urban environment. This project translated this ideal situation into a sound scientific research that can offer concrete public health impact.

Slowing Down Non-Communicable Chronic Diseases in Mali with Inclusive Education and Learning Nests

Author(s): Maryvette Balcou-Debussche1, Xavier Debussche2, Stéphane Besançon3
Affiliation(s): 1LCF-UMR 8143 CNRS, Université de La Réunion, Saint-Denis, La Réunion, 2CHU de La Réunion, Saint-Denis, La Réunion, 3ONG Santé Diabète, Bamako, Mali
Name your project or intiative: Slowing down the burden of non-communicable chronic diseases by developing an inclusive educational approach: the learning nests
1st country of focus: Mali
Additional countries of focus: Burundi, Reunion, Mauritius, Botswana, Mayotte, French Guiana
Relevant to the conference theme: Non-communicable chronic diseases
Summary: To face the burden of non-communicable chronic diseases efficient and feasible actions devoted to prevention and education are urgently needed. Emerging from a co-construction of expertise of social scientists and medical world, the theoretically-based learning nest approach is matched to the special characteristics of chronic diseases in plural contexts. Complete sets of educational materials can be used for small groups of learners at close quarters by trained social workers or peer educators. The first implementations in Africa and Indian Ocean have yielded results that open the way to a constructive reflection on the issues of prevention in chronic diseases.
What challenges does your project address and why is it of importance?: Most African countries are faced with contagious diseases (HIV, malaria…) but recent data show the extensive although silent burden of non-communicable diseases. This progression arises in the general context where professionals and institutions are primarily focused on curative aspects, and available drugs are costly. Moreover, human resources for health are scarce and the external resources coming via ONG and/or experts are overall characterized by the translation of questionable occidental models that cannot easily integrate actual culture, languages, literacy, and social dimensions. African countries can nevertheless mobilize major assets, such as community networks and social dynamics, in order to drive, anticipate and convey health and prevention. The present project takes into account the gaps, but also the assets that can be utilised for a sustainable approach, consistent with the localised environment. The challenge consists in changing the predominant paradigm of health care: from the focus on communicable diseases to the consideration of chronic diseases; from the curative perspective to the preventive and educative one; from the costly prevalence studies to the rapid development of actions with the harvest of relevant indicators, and consideration of actors involved in social dynamics (social workers, peers educators).
How have you addressed these challenges? Do you see a solution?: The development the learning nests aims to allow the implementation of preventive and educative actions for adults with high risk of cardiovascular diseases. The action is based on complete sets of educational material for educators and learners, which have been validated by experts from biomedical sciences and from human and social sciences. The approach is focused on the cognitive work of learners for the appropriation of knowledge in group sessions taking into account the specificity of individuals and their integrative environment, as well as conditions needed for action. Sessions take place in a comfortable and non-conflictual environment designed to encourage the emergence of new knowledge and self-esteem (hatching), self efficacy and autonomy in the social, cultural, and economic environments of persons at risk. The development of this approach relies on the identification of existing organizations and voluntary people. During a short-term pragmatic training (3 days), actors focus on the cognitive issues and on the educational approach that aims to promote a long-lasting appropriation of knowledge by the persons concerned with non-communicable diseases. In a first self-assessment session, patients work on their own clinical and biological factors that influence health maintenance (blood glucose, blood pressure, lipids, weight, waist circumference, smoking), before looking at lifestyle effects, and the specific impact of eventual changes, the focus moves to scrutinizing the feasibility of action planning and implementation in real life, taking into account all individual, social, and contextual dimensions. At the end of the session, 2 other complementary sessions are scheduled: physical activity - food and control of fat intake. Sessions are based on specific booklets, for learners and for educators, with a curriculum written protocol (EPMC booklets; Education Prévention des Maladies Chroniques), including those with literacy difficulties. In each session, patients will become aware of issues they can manage on a priority basis, taking account not only of medical dimensions (level of HbA1c, other risk factors, treatment, etc.), but also psycho-sociological, contextual, environmental, cultural and economic dimensions. This approach is possible thanks to attractive and clear supports, presented in the form of educational notebooks, a current and constant adaptation of supports for various contexts in Africa, and continuous work for more than 10 years to model an educational successful basic cycle, along with the potential fast distribution of the information and its relevance for the short and longterm. Finally, the approach integrates the possibility of working everywhere, with a single requisite equipment: supports notebooks and pencils.
How do you know whether you have made a difference?: The learning nests have been trialed from 2004 to 2011, with more than 10 000 persons exposed to cardiovascular and renal diseases, in various settings and countries (Reunion island, Mauritius, Burundi, Mali, French Guiana, Botswana, Comoros). Training sessions of educators have involved more than 500 health educators: health professionals, social workers and peer educators.  In Mali, peers educators have been trained during 3 days sessions and involved in educational sessions for persons with diabetes in Bamako and Sikasso community health centers for more than one year. A randomized control trial is being conducted, with 4 educational sessions: control of cardiovascular risk (blood pressure, waist circumference, smoking, cholesterol, glycaemia), control of Food (balance, fat, carbohydrates), physical activity management, insulin management carried out. 150 persons have been educated.  In Burundi, during the 2 months following the first training session of educators, 12 educational sessions have been held involving 109 subjects at high risk for CVD, and 7 among the ten health structures of the capital Bujumbura (hospitals, health community centers, NGO, diabetic patients associations). During the first six months a total of 60 sessions involving 567 subjetcs, and at 20 months, 2000 subjects have beneficiated from educational sessions. In Reunion, From 2004 to 2007, 394 educational sessions with a mean of 7 high risk patients have been completed : a total of 1220 patients were involved in 1 to 3 sessions (CV risk: 1009 subjects; Food regulation and fats: 837 subjects; exercise: 501 subjects).  Results in terms of intermediate health indicators (blood glucose, blood pressure, waist circumference) are positive and encouraging, as well as the evolution of the total health modifiable risk (calculated on the basis of health indicators collected during educational sessions). Trained educators continue to invest in group education for patients and evolve in education skills and practices. Presentation of this project has been chosen int the pre-selection of « Ten ideas for Africa » in 2010 by Unesco (16 pre-selected projects).
Have you or the project mobilized others and if so, who, why and how?: The Learning nests approach have been implemented in Mauritus for the structuration of diabetes education programmes (APSA Diabetes Care Centre). In Botswana, the supports booklets have been adapted and translated in English and in Setswana, and ministry of heath implemented the project in 2010-2011 for diabetes self-management education and cardiovascular risk prevention. In Mayotte (French Comoros) and in French Guiana, training of educators and health professionals has commenced. 
When your donor funding runs out how will your idea continue to live?: Funding support will help to diffuse the approach in countries who wish to halt the progression of non-communicable chronic diseases, in a long, realist, low-cost way that is adapted to local contexts. This approach is very relevant in towns where new products invade marketplaces, and sedentary lifestyles increase.   The support could take place in diverse forms:- targeting persons who are able to financially support the program.  Training, 1st round, of these ressource persons in order to initiate and implement educational sessions− Development and analysis of first actions and implementations− Training, 2nd round, of resource persons with reflections and feedback on experiences and results.− Diffusion of action and approach via these resource persons. In financial terms, donor funding would thus allow to support the costs generated by− Training− Specific equipment (documentation, internet, computers) − Impression of paper supports − Translation and adaptation to the national and\or regional languages and contexts.

AIDS Knowledge Among High School Students in a District of South India

Project/Initiative Outline:

First Jegan
Last Rupa Subramanian
Name your project or intiative AIDS knowledge among high school students in a district of South India
1st country of focus India
Relevant to the conference theme Communicable chronic diseases; Vulnerable groups
Summary This study was conducted in school children to analyze the degree of knowledge about HIV/AIDS. By this study we conclude that both girls and boys did not aware fully about HIV/AIDS.
Background India is the 2nd largest HIV/AIDS infected country in the world. According to report, 35% of AIDS cases reported are below 25 years of age and 50% of new infections are between 14 to 24 years old. This is mainly due to insufficient knowledge about HIV/AIDS among the children and youths.
Objectives The aim of the study was to assess the knowledge about HIV /AIDS among  school children aged 14-18 years old.
This study was carried out among 3872 students of five high schools in a district of South India to analyze the degree of knowledge about HIV/AIDS prevention, transmission, sign and symptoms. A structured, multiple choice questionnaire was administered.
Results Among 3872, 59% were boys and 41% were girls. All were in the age group of 14-18years. Regarding prevention, 88% of boys and 64% of girls referred condom is the only way of prevention, 75% of both girls and boys inform that have to wash their genital after sexual relation. Regarding transmission, all students inform that sexual intercourse is the main way and 63% informed that it also transmitted through unsafe blood transfusion. Nearly 73% of boy and 42% of girls did not aware about the sign and symptoms of HIV/AIDS. 38% of boys and 55% of girls known the testing method against HIV/AIDS(ELISA). 37% students believed AIDS is a communicable disease and 18% informed it can’t be preventable, 15% students affirmed AIDS is curable. Only 5% of students were aware about the exact mechanism of HIV/AIDS infection, and no students aware about the future co-infection of the disease.
Conclusion Our study concludes that, both girls and boys were not fully aware of the mode of transmissions and prevention of  HIV/AIDS. It is concluded that health education on HIV/AIDS education, without hindering the information, should be incorporated in school syllabus.

School Based Intervention to Prevent Tobacco Use: Sousse, Tunisia

Author(s): Firas Chouikha1, Jihene Maatoug1, Imed Harrabi1, Wahbi Belhadj Khelifa1, Mylene Belkacem1, Sonia Hmad1, Karima Gaha2, Hassen Ghannem1
Affiliation(s): 1Department of Epidemiology, University Hospital Farhat Hached, Sousse Tunisia. 2College Khzema Ouest Sousse, Tunisia
1st country of focus: Tunisia
Relevant to the conference theme: Non-communicable chronic diseases
Summary: The Chronic Disease Prevention Research Center in Sousse Tunisia is implementing a school based intervention to prevent tobacco use among schoolchildren. It is a quasi-experimental study including two groups: a control and an intervention group. This study canvassed a pre- and a post-evaluation of knowledge, attitudes and behaviors about smoking in each group. For this we used a stratified and proportional sampling and included 4003 schoolchildren aged 11 to 16 years in the questionnaire with 1929 and 2074 respectively in intervention and control groups selected from 8 intervention and 8 control schools. Intervention began in 2010 with the training of teachers to animate standardized courses about tobacco use and consequences. We also organized training for young leaders who participated in the animation days to prevent tobacco use in their colleges. On world 'No Tobacco Day' schoolchildren leaders celebrated with the help of the project team in each of 8 intervention schools. They prepared posters which were displayed in the schoolyard. They also distributed pamphlets about consequences of tobacco use and how to prevent smoking. In other schools, schoolchildren leaders presents sketches to their collegues and their teachers. A group of leaders visited the cafeteria of the University Hospital of Sousse and tried to discuss with patients the consequences of tobacco use. They also discussed with health care professionals about their role of models and the importance to help patients quit smoking. This school based intervention is a part of a community intervention program entitled “Together in Health” targeting 3 risk factors for chronic diseases: smoking, physical inactivity and unhealthy diets in 4 settings: schools, workplace, health care setting and neighborhood. This video is to illustrate their activities.
What challenges does your project address and why is it of importance?: Tunisia is facing an epidemiologic transition and cardiovascular diseases represent the primary cause of death. Tobacco use is an important risk factor and is the first preventable cause of death.
How have you addressed these challenges? Do you see a solution?: Tobacco use begins at early age among adolescents. Once this occurs tobacco cessation is more difficult than prevention. So, we propose to implement an intervention to prevent tobacco use among schoolchildren.
How do you know whether you have made a difference?: Our project consists of a research study. It’s a quasi experimental design with intervention and control groups. We began our study by an evaluation of knowledge about smoking, attitudes and behavioral intent before the intervention.
Have you or the project mobilized others and if so, who, why and how?: To implement our project, we have different partners. The National partners are: University Hospital Farhat Hached Sousse, Department of Pediatrics, Regional Direction of Health of Sousse, Primary Health Care, School Medicine Unit, and Regional Direction of Education of Sousse  Regional Direction of Youth, Sport and Physical Education of Sousse Tunisian Heart Foundation, Tunisian Association of Life and Earth Sciences Teachers. The International partners are: National Institute of Health and welfare of Helsinki, Finland, Division of International and Humanitarian Medicine, Department of Community Medicine, Primary Care and Emergency Geneva University Hospitals
When your donor funding runs out how will your idea continue to live?: In our project, we trained teachers and schoolchildren leaders so they could participate with the project team in intervention activities. We rely on teachers and leaders to continue our actions of tobacco prevention.