Geneva Health Forum Archive

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Defining ‘Integrated Care’ and ‘Accessibility’ from an Ambulatory Health Care Provider Perspective.

Author(s) Jinani Jayasekera1, Eberechukwu Onukwugha2
Affiliation(s) 1Pharmaceutical Health Services Research, University of Maryland, Colombo, Sri Lanka, 2Pharmaceutical Health Services Research, University of Maryland, Baltimore, Baltimore, United States.
Country - ies of focus United States
Relevant to the conference tracks Clinical Practice and Hospitals
Summary Defining the key elements of primary care and developing tools to assess these key elements in ‘real world’ practice settings plays an important role in the efforts to promote primary care. ‘Integration’ and ‘Accessibility’ are two such key elements of primary care. Since ambulatory health care providers play a pivotal role in the provision and promotion of primary health care, it is necessary to examine the meaning of these key elements as it applies to their settings. This study aims to contribute to the understanding of ‘integrated care’ and ‘accessibility’ by examining the activities of health care providers in ambulatory care (outpatient) settings.
Background Current health care reform in the United States (US) highlights the role of ‘primary care’ in transforming health care delivery which has led to an increased interest in defining the meaning of ‘primary care’. The Institute of Medicine (IOM) defines primary care as the provision of integrated, accessible health care services by clinicians. IOM further describes ‘integrated care’ to encompass the provision of comprehensive, coordinated, and continuous services that provide a seamless process of care. ‘Accessibility’ refers to the ease with which a patient can overcome financial and cultural barriers to initiate an interaction with the physician for any health problem. Health plan administrators, health policy makers and medical educators have sought to assess ‘integrated care’ and ‘accessibility’ of care provided by physicians to guide health planning and inform future policies. Their efforts are limited by the lack of measures of ‘integrated care’ and ‘accessibility’. The direct and generic assessment of the provision of ‘integrated care’ and ‘accessibility’ is necessary to evaluate primary care.
Objectives To identify measures of ‘integrated care’ and ‘accessibility’ from the perspective of a health care provider in the ambulatory care setting.
Methodology Ambulatory health care providers who participated in the 2004 National Ambulatory Medical Care Survey (NAMCS) were included in the study. NAMCS gathers data on a nationally representative sample of visits to office-based physicians’ practices engaged in direct patient care. NAMCS data includes a variety of patient demographic and clinical information as well as characteristics of care provided in ambulatory care settings. The provision of ‘integrated care’ was identified using seven variables that addressed comprehensiveness (physician self-identifies as the provider of comprehensive primary health care, provides preventive care and care through the life cycle), coordination (working in conjunction with other physicians to provide care, patient referrals are made to the physician by another physician or health care provider) and continuity (physician has established patients and follow-up care is provided). ‘Accessibility’ was defined at the physician level using six measures, one each for young and old patients. Specifically, ‘accessibility’ was defined as the proportion of African American, Hispanic, or Medicaid patients as a proportion of the total number of patients seen by a given physician. Medicaid is a federally and state-funded program to provide health care for low-income individuals in the US. Therefore, patients with Medicaid as a proportion of the physician’s patients were used to characterize financial barriers. Previous studies have shown African American and Hispanic patients in the US are less likely to have access to health services than non-Hispanic whites. Therefore, African American and Hispanic patients seen by the physician were used to characterizing cultural barriers. An exploratory factor analysis was conducted to identify the variables which contributed to the constructs of ‘integrated care’ and ‘accessibility’.
Results The sample consisted of 1,121 physicians. The physician specialties represented in the sample included, general/family practitioners (14%), internal medicine doctors (6%), pediatricians (7%), obstetricians and gynecologists (5%), urologist (7%), psychiatrists (9%) and other specialties. Based on the factor analysis, 11 of the 13 variables contributed to the definition of ‘integrated care’ and ‘accessibility’. Variables related to comprehensiveness, coordination and continuity of care (except care through the life-cycle) were interrelated and contributed to a single underlying construct which defined ‘integrated care’. Care provided to African American, Hispanic and those on Medicaid contributed to two factors related to ‘accessibility’. The two variables quantifying the proportion of African American patients seen by the provider defined one accessibility factor while the separate variables quantifying the proportion of Hispanic and Medicaid patients seen by a provider contributed to defining the second accessibility factor. Therefore, cultural and financial barriers identified by the elements could underlie the definition or meaning of ‘accessibility’.
Conclusion Both ‘integrated care’ and ‘accessibility’ are important constructs of primary care. The elements identified in this study capture the characteristics of ‘integrated care’ and ‘accessibility’ in ambulatory care settings. Therefore, these elements could potentially be used to assess the delivery of ‘integrated care’ and ‘accessibility’ in office based physician practices engaged in direct patient care. This study also provides a basis for further empirical work to develop measures of ‘integrated’ care and ‘accessibility’.

Strengthening rehabilitation care for psychiatric inpatients in Iraq

Author(s) Denis Caharel1, Anne Laure Monod2, Khouloud Hashim3, Naama Shlaba Humaidi 4, Maïté Pahud 5, Renato Oliveira e Souza6, Pierre Bastin7
Affiliation(s) 1department of psychiatry, Hôpitaux universitaires de Geneve, Genève, Switzerland, 2Department of Psychiatry, Hôpitaux universitaires de Genève, Genève, Switzerland, 3Al Rashad Hospital, Al Rashad Hospital, Baghdad, Iraq, 4Al Rashad Hospital, Al Rashad Hospital, Baghdad, Iraq, 5Health unit, ICRC, Genève, Switzerland, 6 Health Unit, Assistance Division ICRC, ICRC, Genève, Switzerland, 7 Health Unit, Assistance Division ICRC, ICRC, Genève, Switzerland.
Country - ies of focus Switzerland
Relevant to the conference tracks Clinical Practice and Hospitals
Summary Al Rashad hospital is the only psychiatric hospital in Iraq. It is supported by the International Commitee of the Red Cross. The University Hospitals of Geneva assisted in strengthening occupational workshops and develop rehabilitation therapy. An assesment of nurses' knowledge, attitudes and practices was carried. Psychiatric nurses were trained in occupational and rehabilitation therapy using interactive methods. From 2011 to 2013, 60 nurses were trained. There was a four-fold increase in the number of patients particpating in rehabilitation therapy. We demonstrated a successful partnership between hospitals in strengthening rehabilitation care for psychiatric inpatients in Iraq.
Background Al Rashad hospital is the only psychiatric hospital in Iraq. It is a 1375 bed hospital located in Baghdad near Sadr city, ten kilometers away from the city centre. About 90% of patients, mostly males, suffer from chronic schizophrenia and are long-term patients residing at the hospital. Due to stigmatization of psychiatric patients, most of patients are admitted upon family's request and discharge from hospital is usually difficult afterwards. The hospital staff comprises of 10 psychiatrists and around 130 nurses, some of them working as rehabilitation staff. Training on psychiatric care or occupational therapy for nurses does not exist. Al Rashad hospital has been supported by the International Commitee of the Red Cross (ICRC) since 1999. The ICRC has performed important construction work in order to increase patient capacity and to improve living conditions. The organization donated material for rehabilitation workshops and appointed a part-time social worker to assist hospital staff. In December 2010, Al Rashad hospital, through the ICRC, requested support from the Department of Psychiatry at the University Hospitals of Geneva (HUG) to access ongoing rehabilitation activities for psychiatric inpatients and to provide directions on further development of rehabilitation care.
Objectives The main objective was to improve renabilitation care including occupational therapy and to allow discharge of psychiatric inpatients and a return to social and professional life.
In December 2011, Al Rashad psychiatric hospital, the ICR and the HUG agreed on the following objectives:
- to measure patient's needs in terms of nursing care;
- to define rehabilitation therapy needs and objectives;
- to develop a training programme suitable to the local context and adapted to the theoretical and practical needs of rehabilitation nurses;
- to conduct training sessions for nurses from all wards;
-to provide ongoing supervision to rehabilitation nurses during workshops with patients.
A sub-objective was to develop family approaches to decrease stigma and facilitate discharge of patients from hospital and return to family life.
Methodology The first mission included an assessment of nurses' knowledge, attitudes and practices about rehabilitation therapy. Interviews and discussions with ICRC and Al Rashad professionals were conducted by the HUG psychiatric expert team made up of an occupational therapist and a specialized psychiatric nurse. Visits of hospital wards and rehabilitation workshops to observe the daily reality of inpatients were also made.
Following this first visit, the training programme was developed in Geneva by the HUG team with the help of two experts in psychiatric training for nurses. Five one-week modules were defined on observational techniques, psychiatric signs and symptoms, attachment theory, Maslow's pyramid, communication, occupational therapy, techniques to conduct individual and group work with patients and their families, and multidisciplinary work. To cover theoretical and practical aspects, interactive methods were used such as presentation of clinical cases by trainees, role games, patients' interviews, occupational therapy exercises and group therapy. Trainees had the opportunity to watch movies about how rehabilitation care is practiced in the HUG and examples of a schizophrenic patient's interview. The movies were then extensively discussed to highlight similarities and discrepancies in psychiatric rehabilitation in Baghdad and Geneva.
The five modules were delivered through a period of eighteen months. In between modules, the trainees were asked to deliver a report on how they introduced techniques learnt into their daily practice and to present it to their peers. Each training module was evaluated by the trainees and comments were integrated to improve the next module.
Translation between Arabic and French was conducted by an Iraqi medical doctor.
In addition, an assessment of nursing care provided for daily life activities in the hospital, on the fields of hygiene, clothing and meals, was conducted by the ICRC health team working in Baghdad in August 2012.
Results From April 2012 to November 2013, 60 nurses of Al Rashad hospital were trained on psychiatric rehabilitation and nursing care, 10 of them attending all five one-week modules. This lead to about a four-fold increase in the number of patients participating in occupational therapy, from an estimated 130 patients in 2011 to 570 in 2013.
Most of the nurses were satisfied or very satisfied with all training modules. During the modules, the trainees requested more practical exercises as well as guidelines for psychiatric care and occupational therapy. At the end of the training programme, all nurses could quote several techniques used in their daily practice.
Improvement in the quality of nurses' assignments and reports was also observed: psychiatric techniques, occupational therapy, empathy for patients and families, multidisciplinary work and involvement of nurses improved module after module.
The audit demonstrated good improvement on basic nursing care, hygiene, clothes and meals in most of the wards. Al Rashad health authorities and the ICRC health team discussed ways of improvement, including human and material resources, for the wards where nursing care was still inadequate.
Conclusion We demonstrated a successful partnership between Al Raschad hospital, the HUG and the ICRC in strengthening rehabilitation care for psychiatric inpatients in Iraq. The HUG training team brought their expertise and experience in rehabilitation care while the involvement of the ICRC was key in delivering continuous support on the ground and approaching health authorities.
This collaboration responded to changes in psychiatric care requested by Al Rashad hospital authorities and staff: the improved participation of patients in rehabilitation and occupational workshops to eventually facilitate the patients' return in social life.
Discussions and exchanges between trainees and trainers on differences in context, culture, experience of rehabilitation care and psychiatric knowledge were the keys to success. Teaching methods and training contents were adjusted after each module following evaluation by trainees.
Further work is now needed to allow patient's rehabilitation outside the hospital.

The Effectiveness of Holistic Care Unit by Using Rate of Patients Revisiting Emergency Department within 3 Days in Taiwan

Author(s) Meng-Chieh Wu1, Li-Sheng Chang2, Hsin-Kai Huang3, Tzu-Chieh Weng 4, Chun-Cheng Zhang 5, Kao-Chang Lin6.
Affiliation(s) 1Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 2Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 3Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 4Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 5Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan, 6Holistic Care Unit, Chi-Mei Medical Center, Tainan City, Taiwan.
Country - ies of focus Taiwan
Relevant to the conference tracks Clinical Practice and Hospitals
Summary Owing to the convenience of health insurance, the numbers of community hospitals has declined in past 20 years in Taiwan. Many patients directly visited medical centers for aid and waited for admission through the gate of emergency department. Overcrowding situations affecting the quality of care at Emergency Departments is an important issue in the Taiwan medical system. The overloading pressure induced the shortage of emergency physicians and nurses. A new department, holistic care unit, was established in Chi-Mei Medical Center in Taiwan in August 2012, to bridge ER and wards in order to provide the continuum of patients care and safety. To our knowledge, it is the first approach in Taiwan.
Background The word 'holistic health' was defined in PubMed database as follows: “Health as viewed from the perspective that humans and other organisms function as complete, integrated unit rather than as aggregate of separate parts”. The definition of a holistic view was that all aspects of people's psychological, physical and social needs be taken into account and seen as a whole. The term is sometimes confused with alternative medicine. Owing to the convenience of health insurance, the numbers of community hospitals has declined in past 20 years in Taiwan. Many patients directly visited medical centers for assistance and waited for admission at emergency departments (ER). In the ER the waiting time was prolonged and more difficult for patients to have beds available. It also influenced the effectiveness of medical treatment. A new department, holistic care unit (HCU), was established in Chi-Mei Medical Center in Taiwan since August 2012, to bridge the gap between ER and wards in order to provide the continuum of patients care and safety.
Objectives Overcrowding situations affect the quality of care at Emergency Departments and is an important issue in  the Taiwan medical system. Many health care workers, including physicians and nurses, are under a lot of working pressure. Many health care workers have retired from emergency department and critical medicine. The shortage of physicians in emergency medicine has significantly decreased the quality of health care. Accordingly, holistic care units were established to improve the quality of medical care. To realize the effectiveness of Holistic Care Units, we evaluated the waiting time for hospitalization and revisits to the Emergency department within 3 days after discharge.
Methodology This Holistic Care Unit was set up close to the Emergency Department to reduce the workload of emergency physicians who were responsible for patients waiting for admission. This newly created unit was composed of seven experienced medical attending staff who would to take care of patients in 8 hours rotations in collaboration with emergency physicians, radiologists, nurses, social workers and cases manager who constituted the team. This team had similar three domains of responsibility: education and training programs, living together in same place, and sharing the medical devices and resources. Each morning there were meetings focused around subspecialties to discuss the constellations with the exception of difficult or surgical cases which ere referred. The case manager followed the condition of post-discharge patients from Holistic Care Unit in order to assure smooth and regular compliance in the transition home without the need for readmittance into the wards. The case manager tracked patients of Holistic Care Unit from January 2013. We used the waiting time period and the rate of revisits to the Emergency Department within 3 days in a proper statistics evaluation of the effectiveness of Holistic Care Unit in our hospital.
Results From February to July 2012 and August to January 2013, before and after the establish of Holistic Care Unit, the rate of waiting period for more than 24 hours for admission at ER declined from 8.55% to 5.4% and from 2.71% to 1.27% for more than 48 hours. The overcrowding conditions at Emergency Departments were largely improved after the establishment of the Holistic Care Unit. The numbers of patients treated at the Emergency Department was 86712 persons from January 2013 to August 2013. The rate of patients revisiting emergency department within 3 days was 3.6% from January 2013 to August 2013. The rate included the patients of Holistic Care Unit. The rate of revisiting Emergency Department within 3 days was 6.1 % among the patients who were discharged from the Holistic Care Unit. The rate of revisiting the Emergency Department within 3 days was 3.2% after eliminating the patients who were discharged against medical advice (DAMA).
Conclusion Overcrowding situations affect the quality of care at Emergency Department and is an important issue in Taiwan medical system. The overloading pressure and the fear of liability has created a shortage of emergency physicians and nurses. A new department, Holistic Care Unit, was established to improve the overcrowding situation and our preliminary results indicate that it has worked effectively. The rate of revisiting emergency department within 3 days is lower if physicians from the Holistic Care Unit suggested early discharge from hospital. However, the overcrowding situation still influences the quality of care. If patients were discharged against medical advice of physicians from the Holistic Care Unit, the rate of revisits to the Emergency Department within 3 days is higher. The major reason for discharges against medical advice is the unavailability of beds and long waiting times for wards. More attention needs to be paid to the long waiting time to admit patients. To our knowledge, this project was the first approach in Taiwan to establish a new department nearby Emergency Department to intervene in the earlier take over patients who waited for admission for advanced and continued care. Beyond above benefits, the mutual interaction bridging Holistic Care Unit and Emergency Department will also cultivate an interdisciplinary teamwork that can achieve the same goals of patients care, education, quality and safety outcomes.

Increasing Access to Surgical Services in Resource-constrained Settings

Author(s): J. von Schreeb*1, S. Luboga2, S. Macfarlane3, M. Kruk4
Affiliation(s): 1Division of International Health, Karoliniska Institute, Stockholm, Sweden, 2Department of surgery, Makere University, Kampala, Uganda, 3Global Health Sciences, University of California San Francisco, 4Health Management and Policy, University of Michigan, School of Public Health, Michigan, United States
Keywords: Surgery, district, hospitals, training

Surgical services provide important preventive and life-saving strategies. Contrary to prevailing opinion, essential surgical procedures can be provided in district hospitals at a cost per DALY equivalent to other well-accepted preventive procedures. An international group of health professionals met last year at the Rockefeller Foundation’s Bellagio Center to develop strategies to raise the profile of surgery and increase access in resource-constrained settings in Africa. The group agreed that the major limiting factor in providing access is the shortage of suitably skilled health workers at district hospitals. The presentation is compiled on behalf of the Bellagio Essential Surgery Group.


 The objectives of the presentation are to: 1) outline what is known about the unmet need for surgical services in Africa and gaps in our knowledge; 2) layout obstacles to access; 3) examine alternative strategies to increase appropriate workforce skills; and 4) call for wider partnerships to integrate surgery within primary healthcare and develop training strategies.


The results are based on a literature review conducted prior to the Bellagio Conference and a synthesis of experiences of participants from Eritrea, Ghana, Kenya, Mozambique, Southern Sudan, Sweden, Tanzania and Uganda, and USA. A significant burden of disease is attributable to surgical conditions in sub-Saharan Africa but that much more evidence needs to be generated in order to better target interventions. A major proportion of these conditions can be treated or prevented cost-effectively at the first referral level but that this will require investments in facility infrastructures and in the training of non-surgeons to perform basic life saving general and obstetrical surgery. Preventive and curative programmes to address basic surgical conditions could strengthen health systems in resource-constrained settings and every effort should be made to develop these programmes in an integrative manner. Preventive and curative surgical interventions are essential to health systems and should to be integrated into primary healthcare strategies.

Lessons learned:

More effort is required to raise the profile of surgery on national and international agendas. In the first instance, there is need for: 1) more research to fill gaps in knowledge; 2) demonstration models of provision of surgical services at district level; and 3) sharing, through partnerships, of country experience in training non-surgeons in basic surgical procedures.

Improving Home-Based Use of Coartem for Malaria Management in Children Under Five Years of Age

Author(s): H. A. Oluyedun1
Affiliation(s): 1Sociology, University of Ibadan, Nigeria
Keywords: Home-based, health volunteers, adherence, malaria management

Malaria is the largest cause of health service attendance, hospital admissions and child deaths in Nigeria. Resistances of plasmodium falciparum to chloroquine and sulphadoxine plus pyrimetamine have led to adoption of policy to use Coartem as the first-line drug of treatment. This is an intervention programme at Orile-Odo in Oluyole L.G of Nigeria. It targets the mothers of under-five children with uncomplicated malaria, using 200 households, 20 health volunteers and four supervisors. A cohort (non-experimental epidemiologic intervention) study will be used a multistage sampling technique. The 20 volunteers and four supervisors are to act as community advocates in sharing the knowledge they have acquired and support mother and caregivers in the community in managing simple malaria.


The objectives of the intervention are - to find out the home based practice, to train the health volunteers on the correct usage of Coartem as the first line of treatment in other to improve adherence, to increase the awareness of the mothers and community about Coartem. To ensure accessibility of Coartem in the community health centres and in the drug sellers shops in the community and to ensure early recognition of symptoms and proper administration of Coartem.


The result showed that: (1) prior to the study the patronage of the Health facility in the community is poor, it is as low as 20% due to lack of knowledge and preference for herbal treatment, after the intervention the hospital cannot meet the demand for Coartem because nearly every mothers in the community wanted to enrolled in the programme; (2) The accessibilty to Coartem improved in the community because the record of the drug dealers in the community all improved on the average of 200%; (3) Early recognition and prompt treatment improved by 100% as revealed by the health volunteers and the drug seller; (4) The adherence to dosage regimen was seen in 90% of the mothers; (5) The health Volunteers and the drug sellers in the community after the training were better informed, and the assessment showed that they passed correct information to the mothers.

Lessons learned:

The programme is an innovative approach to malaria control involving community members. The monitoring ensured validity of the evaluation and made it feasible for replication in other areas in order to inform national scale up. The outcomes of the intervention showed improved and correct use of antimalarial (Coartem) in home management, early recognition and prompt action taken in the malaria management, and compliance to antimalarial drug regimen.

Cultural Competences Help to Improve Healthcare among Indigenous Populations

Author(s): F. G. Arevalo1
Affiliation(s): 1Sociology, Universidad de San Carlos de Guatemala, Guatemala
Keywords: Maternal and neonatal health, indigenous health

Every three minutes, a neonatal death occurs in Latin America. The poorer urban and rural populations are the most affected and within them, in Guatemala, the indigenous population has also the lowest levels of access to basic infrastructure and insufficient coverage to essential maternal and neonatal health services. For instance, in Guatemala, the national neonatal mortality rate is 23 per 1,000 live births but in indigenous communities, the rate can reach up to 39, almost 60% higher. This paper will present a Case Study and Analysis of a new approach for health services provision, focused on Maternal and Newborn Care, developed for rural and indigenous areas of Guatemala. The approach is based in the incorporation, within a Basic Health Team, of an auxiliary nurse, called Mayan Obstetrical Nurse (MON), as a specialized health worker, in charge of neonatal health, within the maternal, newborn and child health (MNCH) continuum of care.


The purpose of this paper is to describe the process followed to design, implement and evaluate the incorporation, of the MON within a Basic Health Team, in rural and indigenous populations of Guatemala, where health service provision is provided by a programme called Extension of Coverage Programme (ECP) through a team, composed by 1 physician, 1 educator and at least one community health worker. Guatemalan Ministry of Health (MOH) provides services to approximately 4.2 million of inhabitants with this modality, sub contracting local NGOs, selected in an open and competitive process, with participation of local authorities and civil society representatives. However, even though, ECP has been working in the country for almost ten years, some indicators as Neonatal and Post Partum care, as well as Maternal Mortality have not been improved substantially.
Given this situation, two years ago the Ministry of Health, with the support of the International Cooperation, developed a curriculum of a new cadre, which was going to be focused to specifically address maternal and neonatal service provision. Beside of detect and refer complications, train and supervise traditional birth attendants, among other activities, some specific characteristics were defined: All participants should be Mayan, must have previous training, of at least 1 year as auxiliary nurse, some experience in maternal and neonatal care, be proficient in the language spoken in communities to serve, and reside in the area of work. MON was in charge of the National School of Nurses, and supported with scholarships granted by USAID.


MON experience is an innovative project in Latin American region, in particular for those countries with predominance of indigenous populations. After almost two years of the incorporation of the MON in health teams, there is solid evidence of improvements in some key maternal-child indicators, but also, there is solid evidence of improvement in the quality of services. In this point is necessary to stress that the majority of health personnel in Guatemala do not speak other languages but Spanish. Among the most remarkable results, there was an important increment for family planning information and use of methods for birth spacing. Post partum and neonatal early detection and care were substantially incremented and by the end of 2,007, more than 100 references were made, for mothers and newborns detected in danger of death.

Lessons learned:

The experience or MON produced several lessons, in relation with health workers and training centres. Cultural competences have showed to be extremely important in order to improve access and quality of health services. It is possible to develop acceptable levels of competence for community health workers to address critical public health issues, as maternal and neonatal death. With relatively small resources, Ministries of Health can be able to train, hire or certify qualified personnel to address key maternal and child health issues.

Hepatitis B and C Transmission

Author(s): R. M. Muhammad*1, I. I. Mahsud2, M. M. Khan3
Affiliation(s): 1Health, Noble Development Network, Lahore, Pakistan, 2NGO, 3NGO, Noble Development Network, Lahore, Pakistan
Keywords: Hepatitis, KABP and Transmission

Even though one out of 10 Pakistanis suffers from the virus of either Hepatitis B or C, the hepatitis-infected population of 15 million awaits the proper implementation of a National Programme for Prevention and Control of Hepatitis in Pakistan to control the deadly disease. Unsafe drinking water, unscreened blood transfusion and the rampant use of used syringes have spread hepatitis, making it one of the biggest concerns for the country’s health managers. According to WHO four to five million people in Pakistan are suffering from Hepatitis B and about four to six million people are suffering from Hepatitis C. It mean over 10 million Pakistanis are suffering from one or the other type of Hepatitis. Objective: To assess the knowledge and practices of barbers regarding transmission risk of HBV and HCV viruses


A cross-sectional survey of barber’s shops in Pakistan was conducted. Barbers were queried about hepatitis, knowledge regarding hepatitis transmission through razor, vaccination, sterilization, and the form of media they use for information and entertainment. Use of instruments on at least 2 clients were observed in each shop. Proportion and their 95% confidence intervals were computed.


Of 96 barbers approached, 12 (13%) knew that hepatitis is a disease of the liver, causing jaundice, it is transmitted through parenteral route and could also be transmitted by razor. During the actual observation of 192 clients, razors were cleaned with antiseptic solution for 22 (11.4%) and reused for 88 (46%) shaves. Conclusion: Level of awareness among barbers about hepatitis and risks of transmission is very low, and their practice of razor reuse that may spread hepatitis is very common. Messages about hepatitis need to be incorporated in media campaigns, in addition to regulation of practices.

Atrial Fibrillation in Africa: Clinical Characteristics, Prognosis and Adherence to Guidelines in Cameroon

Author(s): M. Ntep Gweth*1, M. Zimmermann2, A. Meiltz2, S. Kingue3, P. Ndobo1, P. Urban2, A. Bloch2
Affiliation(s): 1Service de cardiologie, Hôpital Central, Yaoundé, Cameroon, 2Département cardiovasculaire, Hôpital de La Tour, Meyrin, Switzerland, 3Service de cardiologie, Hôpital Général, Yaoundé, Cameroon
Keywords: Atrial fibrillation; Africa; prognosis; guidelines; anticoagulation

The purpose of this prospective study was to characterise the clinical profile of patients with AF in the urban population of a Sub-Saharan African country and to assess how successfully current guidelines are applied in that context.


This prospective study involved 10 cardiologists in Cameroon. Enrolment started on 01.06.2006 and ended on 30.06.2007. Consecutive patients were included if they were >18 years and AF was documented on an ECG during the index office visit.


In this survey, 172 patients were enrolled (75 male; 97 female; mean age 65.8 ± 13 years). The prevalence of paroxysmal, persistent and permanent AF was 22.7%, 21.5% and 55.8%, respectively. Underlying cardiac disorders, present in 156/172 patients (90.7%), included hypertensive heart disease (47.7%), valvular heart disease (25.6%), dilated cardiomyopathy (15.7%) and coronary artery disease (6%). A rate-control strategy was chosen in 83.7% of patients (144/172) and drugs most commonly used were digoxin and amiodarone. The mean CHADS2 score was 1.9 ± 1.1 and 158/172 patients (91.9%) had a CHADS2 score ≥ 1. Among patients with an indication for oral anticoagulation (OAC), only 34.2% (54/158) actually received it. During a follow-up of 318 ± 124 days, 26/88 patients died (29.5%), essentially from a cardio-vascular cause (15/26). Eleven patients (12.5%) had a non lethal embolic stroke and 23 (26.1%) had symptoms of severe congestive heart failure.

Innovative Healthcare for Stroke Patients

Author(s): K. H. Popova1
Affiliation(s): 1Faculty of Public Health, Medical University of Sofia, Sofia, Bulgaria
Keywords: Stroke, practice guidelines, rehabilitation, secondary prevention, mortality risk

Stroke is a leading cause of death and chronic disability in Bulgaria. The objective was to evaluate the risk for death and the factors associated with mortality in stroke patients a year later after the acute clinical phase of the study.


A total of three hundred eleven first-ever stroke patients were included in the analysis a year later after the acute stroke. Data collected included demographics, socioeconomic factors, stroke severity and comorbidities, risk factors, treatments. Data analysis consisted of descriptive statistics and the Kaplan-Meier method and log-rank test to estimate and compare survival curves between groups. Cox proportional hazards model and logistic regression were used to identify risk factors for mortality.


The elderly (75 years and more) are at a greater risk of stroke but also at the high risk of complications and death. The socially disadvantaged are at high risk for disability because of limited access to post-stroke care and rehabilitation. The influence of prognostic factors on survival was investigated by means of the Cox regression model. On multivariate Cox analysis only gender, stroke severity and time duration of hypertention and diabetis were significant independent predictors. This study emphasizes the need to develop integrated well structured and coordinated system for stroke care. Post-stroke care and rehabilitation would substantially reduce the number of deaths and prevention of recurrent stroke. It demonstrates an association between adherence to the principles and guidelines and stroke outcome in prevention, treatment, and rehabilitation of stroke. Implementation of guidelines offers a unique opportunity to identify and help address disparities in healthcare delivery.

Access to Safe Care in Developing Countries

Author(s): Stuart Whittaker1
Affiliation(s): 1Research and Information, The Council for Health Service Accreditation of Southern Africa, Pinelands, South Africa
Key issues:

Recognising the inevitability of unsafe outcomes due to high-risk processes in hospitals, this presentation introduces the concept of the Wedge Model for improving access to safe healthcare. The model comprises two separate, parallel but interdependent processes converging on unsafe care. The model has been developed in response to current events in South Africa. Rarely does a week pass without some minor or major adverse event in a hospital or healthcare facility in this country being reported in the country's media. Post-apartheid hospitals are struggling to deliver quality care to some 43 million people, particularly in the poorer, rural areas. This struggle is even more intense, given resource constraints, the impact of HIV/AIDS, a brain-drain of doctors and nurses and poor performance in both clinical and non-clinical areas. However, evidence is emerging that all countries experience the paradox of healthcare facilities providing some excellent curative care and yet posing a high risk to patients, staff and the community.

Meeting challenges:

The Wedge Model approach offers a mechanism to reduce the risk to patient, staff and community safety and at the same time improve patient care. One side of the wedge is COHSASA's standard improvement programme that aims at improving facility, clinical, management, clinical and non-clinical support and technical systems so that ultimately high levels of excellence are achieved. Work to date shows that services can be improved using QI methods based on standards compliance provided management support and essential resources are available. Clinical standards, however, show a resistance to improvement and adverse events remain a threat. The other side of the wedge is the adverse event monitoring, improving and preventing arm that aims at identifying and improving systems failures that impact on patient safety while they are being improved by the standard improvement arm.

Conclusion (max 400 words):

In this two-pronged approach, serious system failures are identified and interventions prioritised to ensure that patient safety is maximised at any given point during the ongoing quality improvement cycle, which is being implemented simultaneously. The aim is to achieve safe and effective patient care through the Wedge Model by improving systems through incremental standard compliance improvements, on one hand, and regular monitoring and improvement of serious system failures through AE monitoring, route-cause analysis and solutions, on the other hand.