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Strengthening rural health services: Prevalence of diabetes and risk factors among ≥45 year olds in South Tajikistan.

Author(s) Gulzira Karimova1, Barbara Matthys2, Tohirjon Tagoev3, Amridin Abdurahmonov 4, Peter Steinmann 5, Kaspar Wyss 6.
Affiliation(s) Swiss Centre for International Health, Tajik-Swiss Health Reform and Family Medicine Project (Project Sino) , Dushanbe, Tajikistan, Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Zürich, Switzerland, see below, Republican Clinical Endocrinology Centre, Dushanbe, Tajikistan, see below, Republican Clinical Endocrinology Centre, Dushanbe, Tajikistan, Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland, Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland.
Country - ies of focus Tajikistan
Relevant to the conference tracks Advocacy and Communication
Summary The prevalence of diabetes and associated risk factors was assessed among a population aged ≥45 years in two health districts in southern Tajikistan. Study participants answered a questionnaire on risk factors for diabetes and for general chronic diseases. Blood pressure and anthropometric indicators were taken and the blood glucose level determined. Complete data was obtained from 584 participants. One third suffered from a glucose metabolism impairment and one fifth was diagnosed as diabetic. Two third of the participants were overweight and half had an elevated blood pressure. Based on the study findings, diabetes-related health care was strengthened in rural health centres.
Background About two percent of all deaths in Tajikistan are attributed to diabetes. Representative surveys on diabetes and chronic diseases in general are scarce across Central Asia. A study on the utilization of family medicine services from 2011 described the lack of information regarding the diagnostic and management capacity in rural health centres.
The Tajik-Swiss Health Reform and Family Medicine Project (Project Sino) is developing, validating and supporting the implementation of accessible, affordable and sustainable Primary Health Care (PHC) models and family medicine services in pilot districts. The project was launched in 2003 and has so far covered eight health districts. The project outcomes refer to 1) increased involvement of community groups and strengthened family medicine services; 2) improved access to high-quality PHC services and validated models for family medicine; and 3) transfer of experiences to health policy planning and harmonised activities with health sector partners.
A population-based survey was designed to collect reliable information on the prevalence of impaired glucose tolerance and diabetes and risk factors related to diabetes and chronic diseases among the ≥45 year old population in two pilot districts of Project Sino in southern Tajikistan.
Objectives The overall objective was to assess the prevalence of impaired glucose tolerance and diabetes, as well as risk factors associated with diabetes and chronic diseases in general, among rural and urban populations in southern Tajikistan. The quality of care provided to diabetes patients at the level of PHC services was also evaluated.
Specific objectives included:
1) To test a representative population sample for impaired glucose tolerance and diabetes using blood glucose testing and, if indicated, a standard oral glucose tolerance test recommended by WHO, i.e. the 2 hour oral glucose tolerance test (OGTT).
2) To assess risk factors for impaired glucose tolerance and diabetes through an individual questionnaire and measurements of health-related parameters (blood pressure and anthropometric indicators).
3) To assess available services for diabetes patients at the level of PHC services and specialised institutions.
Methodology A cross-sectional survey was conducted in April 2012. The survey was carried out in randomly selected rural and urban communities in two pilot districts of the Project Sino in southern Tajikistan. According to the Ministry of Health, the density of medical personnel in both districts is low compared to other districts. The sample size calculation considered an estimated proportion of 18% of the total population aged ≥45 years. The study was hence designed for a screening of 700 subjects. The study area was stratified into rural and urban communities. The survey communities were randomly selected among all eligible communities of the two pilot districts using a probability proportional to size of population approach. A total of 25 households were selected in each community using the EPI survey approach.
The study was carried out by the Project Sino in collaboration with two endocrinologists specialised in diabetes from the Republican Clinical Endocrinology Centre, district head doctors, specialized medical doctors and registered nurses at hospital and PHC level. Potential participants aged ≥45 years and long-term residents of more than 5 years in the community were recruited in their homes. Participants who gave their informed consent for the study were invited to an interview which included questions on the socioeconomic profile of the household, individual nutritional habits and risk factors for diabetes and chronic diseases in general, and previous diabetes diagnosis and treatment history. Health-related parameters (blood pressure and height and weight) were measured, and the blood glucose level determined after overnight fasting. If indicated, the 2 hour oral glucose tolerance test was performed. Semi-structured interviews were conducted with health care workers, family doctors, specialists and PHC managers at different levels of the health system. A range of diabetes-related services offered were explored, and the status of the national health programmes targeting diabetes. Preliminary results of the study were discussed.
Data was entered into a public statistical package used for data entry including double-entry of one third of the data. Data analysis was performed in Stata Statistical Software. Data analysis focused on standard epidemiological outcomes and the identification of risk factors for impaired glucose tolerance and diabetes.
Results Out of a total of 672 individuals contacted, complete datasets (questionnaires, test results including 2h follow-up test if required) were available for 584 individuals. Less than one third of the participants were male and less than half were aged 45-54 years. 31% of the study participants were affected by a form of glucose metabolism impairment: 21% were diagnosed or had already been diagnosed as diabetic, 5% had impaired glucose tolerance and 4% had impaired fasting glucose. Half of the participants classified as diabetic were aware of their status.
A range of self-reported signs and symptoms were reported significantly more frequently among individuals with diabetes or impaired glucose metabolism. A multivariate regression model controlling for location, sex and age group identified being thirsty (odds ratio; OR=2.22), numbness of hands or feet (OR=1.96) and itching private parts (OR=3.79) as significant.
Conclusion The results indicated high levels of glucose metabolism impairments among the ≥45 year old study population, particularly among men and those aged ≥55 years. A majority was observed to have overweight and high blood pressure, and thus being at risk of chronic diseases. While the population seems to have a certain awareness of diabetes, many of the affected still go without (effective) treatment. The findings of this study were thus made available to key stakeholders such as the family doctors and PHC managers of the project pilot districts, the Republican Clinical Endocrinology Centre and the Ministry of Health, and organizations focusing on chronic disease prevention and care. Recommendations pertaining to strengthen health care and prevention of chronic diseases at the peripheral level were followed-up by the Project Sino in all pilot districts.The awareness for chronic diseases services available in PHC facilities was raised by the following factors:
• Information on chronic diseases is provided by PHC health staff during routine household visits. Blood pressure and anthropometric indicators are measured and identified high-risk patients are invited to the health centre for a blood glucose test.
• Diabetes patients are regularly followed by trained PHC health staff.
Training of PHC health personnel on diabetes and provision of basic diagnostic services has been expanded by the following:
• Training is provided by diabetes specialists of the Republican Clinical Endocrinology Centre to district endocrinologists and to medical doctors of PHC facilities.
• A manual on diabetes including a simple screening form to identify individuals at high risk of diabetes during consultation was developed by the Republican Clinical Endocrinology Centre, and is distributed during trainings.
• Medical kits provided to family medicine practitioners include glucometers.
• Peer-review groups on chronic diseases are regularly held by trained family medicine practitioners. Peer-review groups of trained family medicine nurses recently started.
Awareness on health risks associated with overweight and high blood pressure and prevention is raised by the following:
• Information on chronic diseases and prevention is provided to the population through PHC health staff and community groups. Events such as weddings, parties and meetings in mosques are used as sensitization platforms.
• The health centres are supported by the community groups in identifying high-risk individuals and referring them to the health centre.

Introducing a Model of Cardiovascular Prevention in Slums of Nairobi

Author(s) Steven van de Vijver1, Samuel Oti2, Cate Hankins3, Catherine Kyobutungi 4, Gabriela Gomez 5, Lizzy Brewster6, Charles Agyemang7, Joep Lange8
Affiliation(s) 1Health Challenges and Systems, African Population and Health Research Center, Nairobi, Kenya, 2Health Challenges and Systems, African Population and Health Research Center, Nairobi, Kenya, 3Global Health, Amsterdam Institute for Global Health and Development & University of Amsterdam, Amsterdam, Netherlands, 4Health Challenges and Systems, African Population and Health Research Center, Nairobi, Kenya, 5Global Health, Amsterdam Institute for Global Health and Development & University of Amsterdam, Amsterdam, Netherlands, 6Vascular and Internal Medicine, University of Amsterdam, Amsterdam, Netherlands, 7Public Health, University of Amsterdam, Amsterdam, Netherlands, 8Global Health, Amsterdam Institute for Global Health and Development & University of Amsterdam, Amsterdam, Netherlands
Country - ies of focus Kenya
Relevant to the conference tracks Chronic Diseases
Summary As cardiovascular disease (CVD) has become a leading cause of death in sub-Saharan Africa (SSA), this study describes the development and introduction of a model of cardiovascular prevention in the slums of Nairobi by integrating a public health and private sector approach. The model includes community awareness, a home-based screening service, patient and provider incentives to seek and deliver treatment specifically for hypertension, and adherence support. Theoretical projections proved the model to be highly cost-effective and affordable (1USD/per person per year) and with these promising impressions on the ground, scale up of the service delivery package could be planned.
Background Cardiovascular disease (CVD) is the leading cause of mortality worldwide with up to 80% of global CVD deaths occurring in low- and middle-income countries (LMICs) such as Kenya. By 2030, two million annual CVD deaths are expected in sub-Saharan Africa (SSA).
The rise of CVDs in LMICs is mainly driven by globalization, industrialization, and urbanization, linked to an increased prevalence of CVD risk factors such as tobacco use, alcohol consumption, physical inactivity, and adoption of diets that are high in salt, sugar, and ‘unhealthy’ fat/oils.
The prevalence of behavioural and physiological risk factors for CVD is higher in urban than in rural areas. As the urban population in SSA is projected to increase from 395 million to 1.23 billion by 2050 the burden of CVD in this region is bound to increase.
In Kenya, almost 70% of the urban population lives in slums or slum-like conditions where access to formal health services is limited. With existing health care services suffering from the ‘double burden of disease’ of endemic infectious diseases and emerging chronic diseases, CVDs are treated predominantly at late stages after complications have occurred. This makes care unnecessarily costly and less effective.
Objectives Individual interventions for CVD prevention are both cost-effective and scalable, even in resource-constrained settings. However, evidence is limited on cost-effective and sustainable community-based CVD prevention programs in LMICs in general, and in severely resource-constrained settings such as slum settlements in particular. The aim of this article is to describe the development and introduction of a model that integrates public health and private sector approaches in a cost-effective and sustainable a service delivery package for CVD prevention among urban poor in SSA.
The integration of public health and private sector approaches to tackle CVD prevention could prove useful since, like CVD itself, prevention is closely linked to economic constraints. Such an approach could lead to the development of sustainable and scalable solutions that can be adapted locally to benefit public health in resource-poor settings in SSA.
Methodology Two public health research organisations, the Amsterdam Institute for Global Health and Development (AIGHD) and the African Population and Health Research Center (APHRC), collaborated with a private sector partner, Boston Consulting Group (BCG), to develop a service delivery package for primary prevention of CVD that is suitable for implementation in slum settings in Nairobi, Kenya. Previous studies in this setting and results of an intervention project to improve patient access to treatment for hypertension and diabetes in primary care settings, as well as a comprehensive literature review, informed the conceptual framework. This framework examines the flow of people from awareness of cardiovascular risk factors like hypertension and access to treatment, to adherence and successful blood pressure control. We show the main bottlenecks contributing to low service utilization and loss to follow-up, i.e. becoming aware of CVD risk, accessing screening, seeking treatment, and complying with medication.
We constructed various alternatives of service delivery packages aimed at minimizing the bottlenecks identified in the theoretical framework. As evidence of community-based CVD prevention programs in LMICs is relatively limited, we borrowed important lessons from HIV prevention and control programmes to address CVD. Overall, the cost and potential impact of the various alternative service delivery packages we considered were based on existing literature as well as our knowledge of the study area. The various alternative service delivery packages were then discussed with various CVD prevention stakeholders including policy makers, academic experts, program implementers, researchers, and field staff from previous projects, as well as local community representatives. Health care provision in Kenya is shared equally by the public and private sectors. Therefore, we aimed to include the feedback of representatives from both types of service providers. The objective was to ensure that each component of the service delivery package would address critical bottlenecks in the patient care continuum in a manner that is practical and acceptable within Nairobi slums. Finally, the service delivery packages were ranked based on their theoretical cost-effectiveness to determine the package most likely to succeed.
Results The outcome of the above mentioned process was the final selection of a service delivery package for primary prevention of CVD that comprised four elements: 1) increasing community awareness through announcements at community gatherings and religious services, and a local community radio jingle, 2) improving access to screening for CVD risk factors such as hypertension through household visits, 3) increasing treatment-seeking through vouchers for free treatment and Community Health Worker (CHW) incentives to follow up patients and persuade them to visit the clinic, and 4) improving long-term compliance by setting up patient support groups, subsidizing medication through these groups, providing incentives for CHWs, and sending text messages (SMS) to remind patients of clinic appointments, medication use, and healthy lifestyles.
Overall, we estimated that the final selected service delivery package could avert 248-391 DALYs and cost less than 1 USD per person in the community resulting in a cost-effectiveness between 760-1200 USD/DALY averted. This makes the service delivery package, in theory, a highly cost-effective intervention for CVD risk prevention, with the potential to be sustainable in the resource-constrained settings.
The selected service delivery package began being implemented in August 2012 as the SCALE UP Study in Korogocho, a Nairobi slum with a total population of 35,000. More than one hundred CHWs and field interviewers have been trained during an intense one-week training, after a pilot was completed. The CHWs are incentivized by receiving a fixed amount of money (approximately U$3) for every person they screen and refer to the local clinic, and who demonstrates long term compliance. The estimated total amount of payments and workload is in line with the guidelines for respectively compensation and duties of CHWs from the Ministry of Health. Therefore introduction of the model in the existing public health care structure is feasible. Enrollment of participants is ongoing, with close to 5,000 people 35 years and above already screened. This has led to approximately 900 referrals and 500 patients visiting the clinic. These numbers are close to the projected estimates. The population has reacted positively to the household screening with overall gratitude towards CHWs and low rates of refusals (3%). However, the field work remains challenging due to the dynamic circumstances of the slum setting with high insecurity and mobility.
Conclusion Through the collaboration of public health and private sector a theoretically cost-effective model was developed for prevention of CVD, which is currently being implemented in a Nairobi slum. Collaboration between public health researchers and management consultants introduced innovative aspects to the design and selection of interventions. Based on early HIV screening approaches, public health researchers initially did not consider household screening as a realistic option. However after discussions with the management consultants and a systematic comparison of different combinations of service delivery packages, door-to-door screening seemed likely to be more cost-effective and sustainable within a comprehensive group of interventions than traditional stand-alone screening sites. The underpinning hypothesis is that active engagement of people is needed when products and projects, such as hypertension screening, are relatively unknown. Additionally the household approach significantly reduces costs by combining awareness-raising and screening, two activities that would otherwise be considered separately.
Performance-based payments and incentives as part of prevention and control strategies for CVD are relatively new in the public health sector in SSA. In low-resource settings they may play an important role in making effective use of limited resources. The downside is that rigorous follow up is required to prevent beneficiaries and program staff from manipulating the incentive system, especially in settings of extreme poverty such as slums. Furthermore, we experienced some resistance from key stakeholders such as CHWs to the idea of an incentive-based payment, preferring the old system of fixed remuneration.
From the study onset, we have maintained regular contact with key stakeholders, including the Ministry of Health, City Council of Nairobi, WHO, and leading NGOs such as Médecins sans Frontières. In order to facilitate potential scale-up to other settings, a manual is being developed to show how a similar package of interventions can be designed, implemented, and adapted to different contexts.
If results are in line with the theoretical projections and first impressions on the ground, scale up of the service delivery package could be extended to other poor urban areas in Kenya by relevant policymakers and NGOs. In time, this approach may also prove to be sustainable and scalable elsewhere in Africa

Supporting palliative care in Kinshasa from Geneva: “Palliafamilli”

Author(s) Bénédicte Lasne Hachin1, Dominique Ducloux2, Martin Schneider3.
Affiliation(s) 1Department of palliative care, University hospitals of Geneva, Geneva, Switzerland, 2Department of palliative care, University hospitals of Geneva, Geneva, Switzerland, 3Department of palliative care, University hospitals of Geneva, Geneva, Switzerland.
Country - ies of focus Congo, Democratic Republic of the
Relevant to the conference tracks Chronic Diseases
Summary Since 2011, the department of palliative medicine of the University hospitals of Geneva (HUG) has cooperated with “Palliafamilli”, a non-governmental organisation (NGO) in Kinshasa, DRC. Palliafamilli consists of 1 physician, 3 nurses, 1 physiotherapist, 1 chaplain and 20 volunteers. It aims to improve palliative care for in- and outpatients.Two nurses of the NGO visited the department of palliative medicine of the HUG in April 2012 to get hands-on experience of palliative care in a Swiss referral hospital. In April 2013, two head nurses of the department travelled to Kinshasa, to share experience and to participate in the first international congress on palliative care in the DRC.
What challenges does your project address and why is it of importance? Although mortality due to acute infectious diseases remains high in developing countries, deaths related to non-communicable diseases and HIV/AIDS have increased considerably. However, palliative care is not a priority in international cooperation. The few existing palliative care projects suffer from isolation and often lack local, regional and international recognition. Moreover, the historic influence of the mostly Anglo-Saxon hospice movement favours development of palliative care in countries with English as official language.The DRC is among the least developed countries. Cooperation projects are therefore needed and welcome, particularly to tackle challenges related to chronic diseases.
How have you addressed these challenges? Do you see a solution? The simple approach of repeated mutual visits considerably improves contacts established and maintained by telecommunications. Informal exchange allows sharing of knowledge and practical experience. More formal meetings, like the contribution to the international congress attended by 500 participants, are a platform for more systematic information sharing and for developing a professional and political network.To improve quality of care, capacity building, both in diagnostic approaches and therapeutic possibilities for palliative care, is a cornerstone of the cooperation. It does not only focus on the NGO Palliafamilli, but aims to include the pre- and postgraduate training of nurses in a local school for public health.Palliafamilli is also involved in advocacy for the recognition of palliative care. It has developed contacts with decision makers in the ministry of health and with practicing and teaching health professionals.
How do you know whether you have made a difference? The number of patients followed by Palliafamilli continues to increase, the most obvious indicator of a difference. The NGO is to extend its activities to other areas of Kinshasa and will emphasise home visits to patients in need of palliative care.Further visits from both groups to Geneva and Kinshasa are enthusiastically planned to continue to foster professional training and exchange.
Have you or the project mobilized others and if so, who, why and how? To lessen the seclusion of Palliafamilli, the project contributed to the first international congress on palliative care in the DRC. This congress facilitated networking with local health authorities, health professionals, African palliative care organisations like “Hospice Africa” in Uganda and palliative care associations from Belgium and France. It also strengthened the link to a Belgian NGO that is involved in bilateral cooperation with the DRC. Eventually, contacts to neighbouring Brazzaville are to be established.Advocacy with the ministry of health led to a resolution by the government to set up a technical commission for palliative care and geriatrics. This commission is supposed to develop a national network for palliative care and to integrate palliative care in the training curricula for nurses and physicians.Three staff of a public hospital in Kinshasa are expected in Geneva in October 2013 to become familiar with the approach of mobile palliative care teams.
When your donor funding runs out how will your idea continue to live? The HUG are not involved in financial aspects of the project, but cover the travel expenses only. Therefore, providing continuous funding is not a priority of this cooperation project.Palliafamilli receives funding from a Belgian NGO and from a French association for palliative care.

Violence and Mental Health among Female Sex Workers in Andhra Pradesh, India.

Author(s) SANGRAM KISHOR PATEL1, Niranjan Saggurti2.
Affiliation(s) 1HIV and AIDS Program, Population Council, New Delhi, India, 2HIV and AIDS Program, Population Council, New Delhi, India.
Country - ies of focus India
Relevant to the conference tracks Chronic Diseases
Summary This paper tries to explore the mental health status of Female Sex Workers (FSWs) in Andhra Pradesh state, India and examine the impact of violence against the mental health of female sex workers in two survey rounds (year 2010 and 2012). This paper utilizes data from the two rounds of Behavioural Tracking Survey. Results reveal that nearly two fifth of FSWs were having major mental depression in 2010 compared to less than one third of FSWs in 2012. By highlighting the relative importance of mental health of sex workers, this study is emphasizing the need for government programs’ attention and appropriate care of FSWs.
Background Despite the potential of policy implication, the violence against women and mental health among sex worker has been less explored in developing countries. The World Health Organization highlighted that women’s mental health is an important segment which determines nation’s productivity and development.
Objectives This paper tries to explore the mental health status of Female Sex Workers (FSWs) in Andhra Pradesh state, India and examine the impact of violence against mental health of female sex workers in two survey rounds (year 2010 and 2012).
Methodology This paper utilizes data from the two rounds of Behavioural Tracking Survey (BTS), cross-sectional behavioural surveys conducted during year 2010 (Round-I) and 2012 (Round-II) among FSWs in Andhra Pradesh to monitor key components of the Avahan program. FSWs were recruited for the survey from nine program districts. A probability sampling method was used to select respondents. Conventional cluster sampling was used for non-public hotspots, and time–location cluster (TLC) sampling for public hotspots. In the second stage, respondents were randomly selected within each selected hotspot. A total of 1986 sample for BTS-Round-I (2010) and 1973 sample for BTS-Round-II were selected in Andhra Pradesh. Here the mental health status among FSWs has been measured based on self -reported PHQ-2 mental health scale (major mental depression). Univariate, bivariate and multiple logistic regression analysis were used for the analysis.
Results Results reveal that nearly two fifth of FSWs (39 percent) were having major mental depression during BTS-I (2010) compared to less than one third of FSWs (28 percent) in BTS-II (2012) in Andhra Pradesh. Findings depict, along with violence, mental health status of FSW is significantly associated with the age of first sexual encounter, ashamed of being sex workers, harassment by police, mobility, marital status, economic status, place of residence, HIV status, self-confidence and individual agency. Between the inter survey period, the prevalence of physical violence against FSWs has reduced from 18 percent to 5 percent due to the strategic program interventions in the community. The risk of having major mental depression among those who have faced violence is 44 percent higher with respect to those who have not faced any physical violence in last one year (BTS-I, 2010), whereas the risk has dropped to 29 percent less likely to have major mental depression among those who have faced any physical violence compared to their counterparts in year 2012.
Conclusion From the findings it is quite evident that due to the rounds of Avahan program intervention in the community over the years the violence against FSWs has shown a decline with a reduction in the incidence of major mental depression. By highlighting the relative importance of mental health of sex workers, this study is emphasizing the need for government programs’ attention and appropriate care.

Psychosocial Burden of Sickle Cell Disease on Parents.

Author(s) Ambroise Wonkam 1
Affiliation(s) 1Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, South Africa, Cape Town, South Africa.
Country - ies of focus Cameroon
Relevant to the conference tracks Chronic Diseases
Summary The chronicity of Sickle Cell Disease (SCD) could impair the quality of life of caregivers.
We studied 130 Cameroonian parents with SCD-affected children with a survey instrument including a 38-item stress factors scale.
Parents participants were urban dwellers (89 %), female (80 %), married (60.2 %), and employed (61.7 %). The majority (88.3 %) experienced moderate/ severe difficulty coping with SCD. >3 vaso-occlusive painful events per year was the stressor that most impacted their coping ability. Stressors scores increased with female, single, low education or > 3 children.
In Cameroon, there is a need to ensure affordable access to health-care and activities that would reduce SCD morbidity.
Background In Cameroon population carrier frequencies of SCD range from 8 % to 34 % with a birth incidence of 1.6 %. Although Cameroon has developed a national program for SCD, it remains unimplemented. There is no universal medical insurance coverage in Cameroon and parents and families play a central role in the care of children with SCD.
The chronicity of SCD and the associated frequent hospital attendance and poorer physical state of patients may contribute significantly to the impairment of the quality of life and wellbeing of parents, including marital disharmony, job performance and hindrance from the enjoyment of life.
We reported that Cameroonian parents (i.e. 62.5 %) with a SCD-affected child accepted the principle of termination of pregnancy if the fetus was to be affected. Prenatal diagnosis for SCD was initiated in Cameroon in 2007. In actual practice, to date, 90 % of parents with SCD-affected pregnancies elect for medical abortion. Parents reported that the negative family life experience of SCD, fear of having more affected children, and fear of the poor quality of the child’s health were their main reasons for acceptance of medical abortion for SCD.
Despite the high prevalence of SCD in Africa, there is a paucity of data on the psychosocial impact of SCD on their families
Objectives The general aim of the present study was to assess the perception and severity of various indices of psychosocial burden experienced by parents of SCD patients.Specific research questions were:
(1) How difficult is it to cope with the hospital factors related to the care of your SCD-affected child? 
(2) Has taking care of your SCD affected child made you lose any sort of revenue or financial benefits?
(3) How difficult do you find coping with the clinical manifestations of your SCD-affected child?
(4) Has the problem of caring for your SCD affected child caused any disharmony in your family life?
(5) How difficult is it for you to cope with your SCD-affected child's life?It is felt that this empirical approach towards the assessment of selected psychosocial areas of need, and its implications for care giving, are critical, as the findings could help to plan health resources and services appropriately and guide the provision of necessary support in the future.
Methodology Research Design
This research was a cross-sectional sociological study, using a quantitative approach.Sampling Method
The sampling methods were both purposeful and convenience sampling. Participants were recruited amongst parents of children with SCD. Parents and their affected children were invited to participate via the media. In addition, SCD-patients’ associations were contacted and engaged to collaborate with recruitment efforts.Participants and Eligibility Criterion:
The inclusion criterion was a parent residing with at least one living child with SCD.Questionnaire Format
Socio-demographic and Medical Information Demographic and medical information were obtained from the participants.
Psychosocial Impact of SCD
The general burden and burden of individual stressor factors was determined using a validated instruments for the study of caregiver burden in SCD. The survey instrument included a 38-item stress factors scale using Likert-type statements, evaluating general perceptions of stress and five main specific stressors: hospital factors, financial factors, disease factors (clinical severity), family factors (family life and dynamic) and child factors (perceived quality of life of the SCD-affected child). From individual stressors, the items pertaining to burden, there were four response options with increasing severity: 0, 1, 2 or 3.
A typical item to elicit responses about financial burden (stressors) was “Has taking care of the SCD-affected child made you (the participant) lose any sort of revenue or financial benefits for example loss of job, loss of working hours for business or going to farm or going to sell at the market etc, which has greatly affected the family? The response scale was 0=No such loss, 1=Minor loss of revenues or benefits, 2= Moderate loss of incomes, 3=Major loss of incomes.Setting and Procedure
The study was conducted at the Yaoundé Central Hospital, Cameroon. All face-to-face interviews were conducted in a private consultation room by two investigating physicians: a medical geneticist and a general practitioner.

Data Analysis
Data analysis was performed using the SPSS (Statistical Package for Social Sciences, Chicago; version 17.0). In addition, the skewness of the data informed the use of nonparametric tests. Level of statistical significance was set at p

Results Socio-demographic Characteristics of Participants.
A total of 130 participants responded and all were interviewed. The vast majority (89 %; n=115) lived in the urban areas of Yaoundé, the capital city of Cameroon; median age: 38 years (Range: 22–67), were female (80 %; n=104), Christian (93 %; n=119), married (77.1 %; n=86), living in monogamous households (81.1 %; n=73), employed (61.7 %; n=79), with at least a secondary or tertiary education (82 %; n=105).
Conclusion In conclusion, this group of Cameroonian parents with affected SCD children appears to experience major burden due
to the condition. The financial burden and the frequent vasoocclusive painful crises contributed significantly more than
other measured factors to the psychosocial burden of the caregivers. The results of the study could help to improve
counseling information when advocating for various screening policy, as well as insight for anticipatory counseling
guidance to affected families and patients in psychosocial areas that could need careful planning or specific attention.
The findings emphasize the need for the implementation of policies and practices that ensure easy access to health-care at
affordable costs to SCD-affected families.Policy and Practice ImplicationsThe study provides alternative measures to evaluate caregivers relative to their psychosocial stress. The identification
of those who are not coping effectively is valuable in order to provide appropriate support and benefit from any public
health interventions. The data suggest that high risk caregivers’ groups are monoparental families, especially single
females, unemployed, and caregivers with a low level of formal education. The data reveal the urgent need for schools
to consider adopting flexible tutoring and educational plans involving families with SCD, and for hospital administrations
and parents’ employers to be more aware of the needs of such families.With respect to genetic counseling services, the findings of this study provide insight regarding factors which could
motivate parents to pursue prenatal genetic diagnosis for SCD and may facilitate greater empathy among service
providers. The study also provides data for anticipatory counseling guidance for families with SCD-affected children
in psychosocial areas that may need careful planning or specific attention and support. In addition, the study provides some evidence to enhance counseling information when advocating for screening policies for SCD (neonatal, premarital
or population screening) that are encouraged by the Cameroon National Control Program for SCD.

Predictors of Unintentional Poisoning among Children under 5 years of age in Karachi. A Matched Case Control study.

Author(s) Bilal Ahmed1, Zafar Fatmi2, Rehana Siddiqui3.
Affiliation(s) 1Department of Medicine , The Aga Khan Univesity , Karachi, Pakistan, 2Community Health Sciences, The Aga Khan University , Karachi, Pakistan, 3Community Health Sciences, The Aga Khan University , Karachi, Pakistan.
Country - ies of focus Pakistan
Relevant to the conference tracks Chronic Diseases
Summary Poisoning is one of the main causes of unintentional injury among children. It is the fourth leading cause of morbidity and mortality after road traffic accident, burns and drowning. Majority of these poisoning occur among preschool children under 5 years of age. There is a scarcity of evidence based analytical literature in the area of unintentional injuries, therefore there is need to identify the specific factors in our population in order to provide follow up action that reduces morbidity and mortality in young children and improves the handling of such emergencies by parents and health care workers.
Background Global estimates for childhood unintentional poisoning are not available and most of the existing information is from developed countries. There were an estimated 86,194 child poisoning incidents treated in United States hospital emergency departments in 2004, amounting to 429.4 poisoning per 100,000 children. Since morbidity is comparatively more associated with unintentional poisoning than mortality, non fatal incidents occur more among children of 1-4 years of age. Previous studies identified kerosene, petrol, medicines, insecticides, and household cleaning products as major hazards for poisoning incidents in children less than 5 years. Kerosene oil poisoning is commonly reported from developing countries. For cooking and lighting the main fuel use is paraffin (kerosene) and petrol for power generators, which is often stored under the beds in beverage or other empty containers. Unintentional ingestion of medicines both over the counter and prescription drugs, by young children and toddlers has been often reported. Similarly, household chemicals like bleach, toilet cleaners are also common substances involved in unintentional poisoning. Pakistan is a developing and low income country and, with more than 24 million children under 5 years of age, is highly vulnerable to such incidents.
Objectives There are few descriptive surveys available from Pakistan on unintentional childhood poisoning. However, there is a scarcity of analytical based epidemiological studies that has focused on factors within households that are associated with poisoning among young children. Epidemiological studies investigating the etiology of unintentional poisoning in children have been reported from the developed world or Malaysia and Greece.
As mentioned earlier, the majority of poisoning incidences occur inside home, however factors associated with household environment, behavioral issues of children and storage practices of caregivers have not been studied in our setting before. Monitoring of acute poisoning is important for health authorities because they can identify major factors involved in a particular population to prevent them. There is a scarcity of evidence based analytical literature in this area of unintentional injuries, therefore there is need to identify the specific factors in our population in order to enact follow up action that reduces morbidity and mortality in young children and improves handling of such emergencies by parents and health care workers. Moreover, it would help in designing appropriate strategies and interventions to create awareness in general population to reduce the burden of childhood poisoning.The key objectives are to determine the factors associated with poisoning among children under-5 years of age reporting to Emergency rooms of tertiary care hospitals in Karachi.
Methodology This study was conducted in the ERs of three large tertiary care hospitals in Karachi: the Aga Khan University Hospital (AKUH), the Civil Hospital Karachi (CHK), and the National Institute of Child Health (NICH). AKUH, a private hospital, caters
for 12 000 paediatric patients annually, whereas CHK and NICH are public hospitals, and receive approximately 150 paediatric patients in the ER daily. These hospitals provide services for the upper, middle and lower socioeconomic classes of the Karachi population. The study data were collected from August 2008 to March 2009. The investigation was a matched case control study. All consecutive poisoning cases were enrolled in the study, including gravely ill children or those who died either in the ER or before reaching the hospitals during the study period.The cases were defined as being children under 5 years of age with oral ingestion of any noxious substances. They were recruited into the study after a definite diagnosis of accidental intake of poisoning was made by the attending physician of the respective hospitals. The noxious agents considered for poisoning in this study were any substance that had the
potential for toxic effects and included medicines, insecticides, pesticides, petroleum products, household chemicals, and cosmetics. Children admitted for food poisoning, adverse drug reactions, and poisoning with animal venom were excluded. Controls were selected from the ER of the same hospitals and comprised of children with complaints other than poisoning. Controls were matched for age (66 months) and sex, as these were the known confounders. Three control children per case visiting the ER of the same hospital within 48 h of case identification were enrolled for the study. Children with symptoms of chronic illness such as known cases of cardiac disease, renal failure, chronic pulmonary disease, cancer patients, and road traffic accidents were excluded from the study sample. Children brought from nearby areas outside Karachi were not included in the study. Caregivers were interviewed using a structured questionnaire. Information on the sociodemographic characteristics of the child and caregiver, and the storage practices for medicines and chemicals in their household, were obtained.
Sample size: a total number of 120 cases and 360 controls were required to achieve the objectives of the study. Multivariable conditional logistic regression analysis was done and adjusted matched odds ratios (mORs) were calculated.
Results The data included 120 cases and 360 matched controls. Incidental uptake of medicines was the most common type of poisoning, followed by kerosene oil ingestion. Similarly, the majority of the incidents of poisoning occurred in the bedroom followed by the drawing/dining room, courtyard and kitchen. Among all the subjects enrolled during the study period, only one cased who had ingested medicine (warfarin) died. The majority of poisoning incidents occurred among children 1-2 years of age. Among the cases medicinal users at home, history of previous poisoning incident, and child behaviour reported as aggressive were more prevalent than among controls. Similarly, the proportion of parents living apart and living in a nuclear family system was more in cases than controls. The storage practices of medicines and chemicals showed that the proportion of unsafe storage of chemicals that is not at a height >2 m is greater among cases than controls (30.8% vs 16.7%). Similarly, more households of cases (80%) stored unlocked chemicals compared to controls (56.1%). Among the cases the safe storage of medicine at a height >2 m was 64.2% compared with 75.3% for the controls. Only 8.3% of the caregivers of cases reported that they kept medicines locked, compared to 23.6% of the controls. However, when these variables were combined to make a composite variable it showed that 14.2% of the caregivers of cases reported storing both chemicals and medicine unsafely, compared to 5.8% of controls. Adjusted analysis shows that, accessibility to hazardous chemicals and medicines was significantly associated with poisoning. Unsafe storage of either chemicals or medicines occurred 1.5 times more in cases compared to controls. Similarly, unsafe storage of both chemicals and medicines occurred 5.6 times more in cases compared to controls (mORadj 5.6, 95% 95% CI 1.9 to 16.7). Storage of kerosene and petroleum in soft drink bottles occurred 3.8 times more in cases compared to controls (mORadj=3.8, 95% CI 2.0 to 7.3). Cases were 8.2 times more likely to be aggressive compared to controls (mORadj=8.2, 95% CI 4.2 to 16.1). Similarly, the reporting of a previous poisoning incidence was 8.6 times more in cases compared to controls (mORadj=8.6, 95% CI 1.7 to 43.5). The low level of mother’s education was strongly associated with poisoning in children.
Conclusion In conclusion, we found that accessibility of hazardous chemicals and medicines due to unsafe storage, reported child behavior as aggressiveness, history of previous poisoning, low maternal education, storing of kerosene and petroleum in soft drink bottles, and low socio economic status were associated with increased risk of unintentional poisoning among children under-5 years of age living in Karachi. Some of these factors, particularly storage practices, are potentially modifiable and efforts to reduce the prevalence of unsafe storage could have the benefit of reducing the incidence of unintentional poisoning in this population. To curtail the number of childhood poisoning incidents understanding its related preceding factors in particular settings are necessary. Future directions in the field of childhood poisoning involves a number of strategies including the incorporation of better-tested and more refined educational, legislative, and environmental intervention strategies. As mentioned earlier, there is a scarcity of literature in the area of childhood injuries. The large community base studies, emergency room surveillance system for overall unintentional childhood injuries including poisoning, and population base follow-up studies helps to determine the predictors. Studies of risk factors have to be conducted and analyzed with due regard to possible confounding variables and interaction between factors. Similarly, cost effective and sustainable intervention needs to be launched, to see if it decreases the burden. Qualitative focus group discussions with parents of young children about real and perceived barriers to calling the local poison information center, resources for poison prevention messages, and ideas about public awareness campaigns should also be done.
Intervention and longitudinal studies can further provide the necessary evidence in understanding the behavioral issues of children, parents and other care givers that could lead to unintentional ingestion of harmful substances to further establish temporality and causal association.

The State of Global Mental Health Services

Author(s): B. Saraceno 1
Affiliation(s): 1WHO, Geneva, Switzerland
Key messages:

1 – Mental, neurological, and substance use (MNS) disorders are prevalent in all regions of the world and are major contributors to morbidity and premature mortality.
2 – The resources that have been provided to tackle the huge burden of MNS disorders are insufficient, inequitably distributed, and inefficiently used and this generates a serious treatment gap.
3 – Success in implementation of the programme rests, first and foremost, on political commitment at the highest level.

Summary (max 100 words):

Mental, neurological, and substance use (MNS) disorders are prevalent in all regions of the world and are major contributors to morbidity and premature mortality. The stigma and violations of human rights directed towards people with these disorders compounds the problem. The resources that have been provided to tackle the huge burden of MNS disorders are insufficient, inequitably distributed, and inefficiently used, which leads to a treatment gap of more than 75% in many countries with low and lower middle incomes. The World Health Organization (WHO) has recognized the need for action to reduce the burden, and to enhance the capacity of Member States to respond to this growing challenge. The objectives of the WHO’s programme are to reinforce the commitment of all stakeholders to increase the allocation of financial and human resources for care of MNS disorders and to achieve higher coverage with key interventions especially in the countries with low and lower middle incomes. The Programme attempts to deliver an integrated package of interventions, and takes into account existing and possible barriers for scaling up care. Priority conditions were identified on the basis that they represented a high burden (in terms of mortality, morbidity, and disability); caused large economic costs; or were associated with violations of human rights. These priority conditions are depression, schizophrenia and other psychotic disorders, suicide, epilepsy, dementia, disorders due to use of alcohol, disorders due to use of illicit drugs, and mental disorders in children. The obstacles that hinder the widespread implementation of these interventions must also be considered, together with the options that are available to deal with these. Success in implementation of the programme rests, first and foremost, on political commitment at the highest level. One way to begin to achieve this is to establish a core group of key stakeholders who have multidisciplinary expertise to guide the process. Assessment of needs and resources by use of a situation analysis can help to understand of the needs related to MNS disorders and the relevant health care, and thus to guide effective prioritization and phasing of interventions and strengthening of their implementation. Development of a policy and legislative infrastructure will be important to address MNS disorders and to promote and protect the human rights of people with these disorders. Decisions will need to be made as to how best to deliver the chosen interventions at health facility, community, and household levels to ensure high quality and equitable coverage.

Conclusion (max 400 words):

Successful scaling up is the joint responsibility of governments, health professionals, civil society, communities, and families, with support from the international community. An urgent commitment is needed from all partners to respond to this urgent public health need.

Lessons learned:

Adequate human resources will be needed to deliver the intervention package. Most countries with low and middle incomes do not assign adequate financial resources for care of MNS disorders. Resources for delivery of services for these disorders can be mobilized from various sources – e.g. by attempts to increase the proportion allocated to these conditions in national health budgets; by reallocation of funds from other activities; and from external funding, such as that provided through developmental aid, bilateral and multilateral agencies, and foundations.

Sickle Cell Disease in Cameroon: The First Neuropsychological Normative Data for School-Aged Children

Author(s):

N. Ruffieux*1, C. Hauert1, R. Sztajzel2, E. Mayer3, E. Mbong4, C. Eta4, A. Kengne4, R. Njengoue Ngamaleu4, R. Foncham Doh4, A. K. Njamnshi4

Affiliation(s): 1Faculty of Psychologie and Education Sciences, University of Geneva, 2Neurology Services, 3Neuropsychology Unit, University Hospitals of Geneva, Switzerland, 4Neurology Department, Central Hospital Yaounde, Cameroon
Keywords: Sickle cell disease, neuropsychology, normative data, cognitive deficits, cerebrovascular accident
Background:

Sickle cell disease (SCD) is caused by an abnormal type of haemoglobin called haemoglobin S which is inherited as an autosomal recessive trait. In Cameroon, the prevalence of this disease is 2 to 3 % (among 16 millions habitants). Cerebrovascular accidents are one of the main causes of mortality for SCD patients, responsible for persistent neurological and/or neuropsychological deficits associated with ‘silent infarcts’. Our previous work has shown that at least 6.7% of SCD patients in Yaounde – Cameroon present with this complication, not including silent infarcts (Njamnshi et al. 2005; Njamnshi et al. 2006). Within the framework of collaborative research conducted in the Yaounde Central Hospital (YCH) on the cerebro-vascular complications of SCD in Cameroon including Transcranial Doppler screening of at risk patients, the cognitive functioning of the sickle cell children was to be assessed using a neuropsychological battery of tests. For this, norms had to be established in a healthy population. These norms allowed the performances of sickle cell children to be compared with the ‘normal and average’ cognitive functioning in that socio-cultural context.

Summary/Objectives:

In the first phase, a battery of neuropsychological tests was set up considering the Cameroonian cultural and linguistic specificities. After a pilot study on 20 subjects, the cognitive tests were adapted following the difficulties met. Twelve neuropsychological tests were adapted for the study: the Purdue Pegboard Test, the California Verbal Learning Test for Children, the Color Trails 1 and 2, Hand Movements (K-ABC), Verbal Fluency Test, a cancellation task, the Continuous Performance Task (CPT) and 4 subtests from the WISC-IV (Digit Span, Letter-Number Sequencing, Coding and Block Design). The duration of the examination was approximately 1h30. The neuropsychological battery was designed to assess mainly the executive functions, shown in previous studies to be the most deficient among these patients. During the first 4 months, the neuropsychological team (4 Cameroonian psychologists and a Swiss neuropsychologist) recruited 134 healthy children, from schools in Yaounde and among the families of the caregivers of the YCH (60 boys) aged 3 to 20 years old (mean = 11.48, SD = 4.24). The children were divided in 7 age-groups (3-5, 6-7, 8-9, 10-11, 12-13, 14-16, 17-20 years old), so that the cognitive performances of the sickle cell children could be compared to the corresponding age group. Ethical clearance for research was obtained from the National Ethics Committee of Cameroon and of the University Hospitals of Geneva.

Results:

The data analysis allowed determining pathological limits for each test, using a method of centile (limit score at centile 5). Means and standard deviations of each test were calculated as well (Table not shown). The scores of the sickle cell child can afterwards be compared to the limit of the corresponding age group for each test, allowing us to determine if the cognitive functioning of a given child is within the range of the healthy children of his/her age. This battery will be used to follow the cognitive evolution of the sickle cell patients for the first time in Cameroon, and will also be useable in other frameworks.

Lessons learned:

The feasibility of a classical neuropsychological assessment of Cameroonian children was demonstrated and proved useful in the approach of SCD patient evaluation. Several adaptations of the tests to the Cameroonian context were necessary and achieved successfully. It was not possible however for this neuropsychological battery to be adapted to the younger children (aged 3 to 5). Given that the mean age of the first brain infarcts is around 6 years, we decided to conduct another study using a specific cognitive battery for the 3 to 5 years-old children.

Observations on the Disease Burden in Cambodia: The Top Three Non-Communicable Diseases (NCDs) at the Sihanouk Hospital Centre of HOPE (SHCH)

Author(s): K. Lim*1, A. Finckh2, D. Liu3, C. Haener4
Affiliation(s): 1Medical Department, Sihanouk Hospital Centre of HOPE, Phnom Penh, Cambodia, 2Rheumatology, University Hospitals of Geneva, Switzerland, 3Hospital Director, 4Surgical Department, Sihanouk Hospital Centre of HOPE, Phnom Penh, Cambodia
Keywords: Burden disease, non communicable disease, Cambodia
Background:

The Cambodian civil war of 1975-1979 affected all aspects of society. The purpose of the Khmer Rouge movement was to reorganize Cambodia into a rural agrarian society based entirely on subsistence farming. With a lack of physicians and institutions in which to train them, over the next 15 years Cambodia struggled to rebuild its public health infrastructure. Efforts to combat the HIV epidemic brought prevalence down from 4% in 1997 to 0.9% in 2005. It seems that NCDs are increasing due to the fast growth in economic development. The prevalence of diabetes in Cambodia is surprisingly high with total of 255,000 (2% of total population), according to WHO and World Diabetes Foundation information made public locally in November 2007. To date, there has been no systematic analysis of available data of NCDs in Cambodia.

Summary/Objectives:

The purpose of this cohort is to identify the proportion of NCDs at the SHCH, a charity NGO hospital in Phnom Penh, Cambodia. From January 2000 until December 2007, a retrospective cohort of 32,082 patients (excluding TB and HIV) were seen and treated at SHCH. During their visits the patients received full physical examinations and complete diagnostic workups, including personal histories.

Results:

Demographics of the patients: mean age 45 (15-70), women 61% (19,663). The top ten NCDs were as follows: 20% (6325) with hypertension, almost 18% (5723) with diabetes without complication and another 5% with peripheral neuropathy; 5% (1663) with cardiovascular diseases, including rheumatic heart diseases; 3.5% with toxic goiter, 3.5% with any arrhythmia, 3.5% with ischemic heart disease; around 3% with dyspepsia; 2% with chronic renal failure from any time of diseases; and 2% with asthmas/COPD. Additionally data report on the advance state of Rheumatology related less then 1% (total of 240).

Lessons learned:

There is a high proportion of NCDs due to the accumulation of patients as we are the only adult hospital in–country offering care free of charge. Further studies nationwide should be conducted to show prevalence of these diseases. Additionally the health system should increase its efforts to provide services for chronic disease at facility level and put more emphasis on primary healthcare in the community. As a training institution, we have and need to incorporate teaching in assessment and treatment of NCDs. On the national level efforts need to be made to develop training curriculum in medical school and training institutions with a focus not only on communicable diseases but also on NCDs.

Access to Insulin and Diabetes Care in Mali, Mozambique and Zambia

Author(s): D. H. Beran*1, J. S. Yudkin1, M. de Courten1
Affiliation(s): 1International Insulin Foundation, London, UK
Keywords: Diabetes, Sub-Saharan Africa, access, Latin America
Background:

Access to care of Type 1 diabetes in developing countries is often difficult due to various factors. The aim of this work was to identify what barriers exist and relate these to estimated life-expectancy.

Summary/Objectives:

A Rapid Assessment Protocol developed by the International Insulin Foundation was used to collect information from government organisations at central, regional and peripheral health units, as well as patients and their carers. Cross checking between different data sources was used to establish validity. Between 100 and 200 interviews/discussions were undertaken in each country.

Results:

The overall life-expectancy for a child (0-14) with Type 1 diabetes was 0.96 years in Mali, 3.5 years in Mozambique, 22 years in Nicaragua and 11.2 years in Zambia. Estimates of life-expectancy in Mozambique differed by around 6-fold between the capital city and the rural area, but these differences were only twofold in Zambia. In Mali it was estimated that 90% of the country’s known diabetic patients received care in the capital city. Insulin was available in sufficient amounts at the national level in all countries, but supplies to peripheral units were more variable. Most health units in Mali and Mozambique lacked any means of measuring blood or urine glucose, for diagnostic or monitoring purposes. Knowledge of Type 1 diabetes was poor among most health workers in these countries.

Lessons learned:

Type 1 diabetes is associated with poor outcomes in developing countries, particularly away from urban hospitals. Better outcomes were observed in Nicaragua and Zambia due to access to free insulin, health worker training and advocacy by diabetes associations. Improvements in healthcare systems, pharmaceutical supply, and health worker training are important to tackle Type 1 diabetes and will likely have an impact for other non-communicable and communicable diseases.