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GHF2014 – PS29 – Information and Communication to Promote and Facilitate Health

10:45
12:15
PS29 THURSDAY, 17 APRIL 2014 ROOM: LEMAN
ICON_QA
Information and Communication to Promote and Facilitate Health
MODERATOR:
Prof. L. Suzanne Suggs, PhD, MS, CHES, Senior Assistant Professor of Social Marketing and Head of BeCHANGE Research Group, Institute for Public Communication (ICP), Faculty of Communication Sciences, Università della Svizzera italiana, Switzerland
SPEAKERS:
Smartphones to Improve Health Workers Performance and Rational of Drug Use for Management of Childhood Illnesses in a Low Resource Settings
Ms. Clotilde Rambaud-Althaus, MD, PhD candidate, Epidemiology and Public Health Department, Swiss Tropical and Public Health Institute, Switzerland
Prof. Don de Savigny
Head, Health Systems Interventions Research Unit, Department of Public Health and Epidemiology, Swiss Tropical and Public Health Institute, Switzerland
Dr. Allison Goldberg
Director, Global Corporate Affairs, Global Corporate Affairs Anheuser-Busch InBev, United States
Dr. Anthony Adoghe
Research PhD student in Public Health at the University of Essex and founder of Adoghes’ Online Public Health Clinic, United Kingdom
Ms. Sabina Beatrice-Matter
Manager Health Projects, Novartis Foundation for Sustainable Development Switzerland
OUTLINE:
PROFILES:

Suggs photo_sept 2011Prof. L. Suzanne Suggs

Professor Suggs is an Assistant Professor of Social Marketing and Head of the BeCHANGE Research Group in the Institute for Public Communication, Faculty of Communication Sciences, at the Università della Svizzera italiana (USI), in Lugano Switzerland. She is also Director of the USI Sustainability Incubator (USI-SINC). She received a BBA in Marketing at University of North Texas (USA), a MSc and PhD in Health Studies at Texas Woman’s University (USA), and a Post-doctoral fellowship at McMaster University (Canada).

Suzanne’s research focuses on behavior change communication through information and communication technologies. She examines the determinants of behavior and tests innovative digital communication strategies, delivered through ICT, and the influence on health behaviors. The majority of her work focuses on eating and physical activity behaviors, but also does research on alcohol, tobacco, decision-making, vaccination uptake, hand washing, HIV testing, medication compliance, self-management of conditions and therapy, and consumption behaviors.

Prior to joining the faculty in Lugano, she was Assistant Professor of Health Communication, Department of Marketing Communication, at Emerson College and Adjunct Assistant Clinical Professor in the Department of Public Health and Family Medicine at Tufts University School of Medicine (Boston, Massachusetts, USA). She has a wealth of industry experience, working with pharmaceutical companies, health insurers, foundations, organizations, and multi-media communication companies. She is a Co-Founder and on the Executive Board of the European Social Marketing Association and is on the Editorial Board for the Journal of Health Communication: International Perspectives. She teaches graduate level courses in Social Marketing, Focus Group Methods, Research Methods, and Media Skills. And for the second year in a row, Suzanne will teach a course on ” m-Health: Mobile Communication for Public Health”, in the Swiss School of Public Health+ Summer School this August in Lugano.

Rambaud Profile PhotoMs. Clotilde Rambaud-Althaus

Married, mother of two girls and MD, specialist in General Medicine (France), with a focus on Tropical Medicine and International Health. Large field experience as clinician or research scientist with Médecins Sans Frontières and Epicentre in Democratic Republic of Congo, Lebanon, Central African Republic, Cameroun, and Swaziland. Back in Switzerland after three years of expatriation in Tanzania, from 2010 to 2012 as PhD Student with Swiss Tropical and Public Health Institute and University of Basel in the field of malaria, non-malarial fever, and management of childhood illnesses. Currently finishing a PhD thesis and working as a clinician in Travel Medicine Unit of University Hospital of Lausanne.

Don de Savigny_squareProf. Don de Savigny

Professor de Savigny is an epidemiologist and public health specialist and currently Head of the Health Systems Research Unit in the Department of Epidemiology and Public Health at the Swiss Tropical and Public Health Institute, University of Basel.  He has extensive experience in conducting and facilitating health research in developing countries and has lived and worked for many years in Africa.  He chairs or is a member of a number of WHO, RBM, Global Fund, and TDR advisory committees and networks such as COHRED, the Health Metrics Network and the INDEPTH Network.  His current research focuses on interventions to strengthen health systems in developing countries, and on the health system effects of Global Health Initiatives for scaling up access.

Goldberg_Badge_squareDr. Allison Goldberg

Allison Goldberg is a recognized public health expert who has worked with private and public sector leaders around the world on topics ranging from HIV/AIDS to maternal and child health, health innovation scale-up, and health systems strengthening. Allison has published widely and presented on these topics at national and international conferences and high-level meetings with the United States Government and United Nations. Allison spent eight years working with consumer health and pharmaceutical companies, health providers, national and local governments, and non-governmental organizations all sharing interests in developing and implementing evidence-based solutions to address global health challenges. Allison is currently the Director, Global Corporate Affairs, Anheuser-Busch InBev (ABI). In this role, Allison manages and helps develop ABI’s evidence-based research approach to advancing prudent policy related to alcohol and global health. She manages a portfolio of public health initiatives and ensures that research and best practices are embedded in these initiatives. Allison earned a B.A. in Political Science from the University of Michigan, Ann Arbor and an interdisciplinary Ph.D. in Public Health and Political Science from Columbia University.

SabinaMs. Sabina Beatrice-Matter

Sabina Beatrice-Matter is Project Manager at the Novartis Foundation for Sustainable Development for some of the foundation’s healthcare projects, namely the primary healthcare program in Mali, the Tanzanian Training Centre for International Health as well as ICATT and IMPACtt – two eLearning initiatives aimed at improving training in maternal, newborn and child health in collaboration with WHO and the Swiss Tropical and Public Health Institute. From 2008 to 2013, Sabina was also in charge of Communication’s at the Novartis Foundation. Prior to joining the foundation, Sabina worked for the communications department at Novartis and did internships with the Swiss national television in Berne and the news agency FSN in Washington DC.

Sabina is currently doing an MBA in International Health Management at the University of Basel (graduation expected in 2015). She holds a Master’s degree in International Relations from the Graduate Institute of International and Development Studies in Geneva and the University of Salamanca in Spain and studied one year of Journalism at the Shenandoah University, USA.

Dr. Suzanne Suggs

Professor Suggs is an Assistant Professor of Social Marketing and Head of the BeCHANGE Research Group in the Institute for Public Communication, Faculty of Communication Sciences, at the Università della Svizzera italiana (USI), in Lugano Switzerland. She is also Director of the USI Sustainability Incubator (USI-SINC). She received a BBA in Marketing at University of North Texas (USA), a MSc and PhD in Health Studies at Texas Woman’s University (USA), and a Post-doctoral fellowship at McMaster University (Canada).

Suzanne’s research focuses on behavior change communication through information and communication technologies. She examines the determinants of behavior and tests innovative digital communication strategies, delivered through ICT, and the influence on health behaviors. The majority of her work focuses on eating and physical activity behaviors, but also does research on alcohol, tobacco, decision-making, vaccination uptake, hand washing, HIV testing, medication compliance, self-management of conditions and therapy, and consumption behaviors.

Prior to joining the faculty in Lugano, she was Assistant Professor of Health Communication, Department of Marketing Communication, at Emerson College and Adjunct Assistant Clinical Professor in the Department of Public Health and Family Medicine at Tufts University School of Medicine (Boston, Massachusetts, USA). She has a wealth of industry experience, working with pharmaceutical companies, health insurers, foundations, organizations, and multi-media communication companies. She is a Co-Founder and on the Executive Board of the European Social Marketing Association and is on the Editorial Board for the Journal of Health Communication: International Perspectives. She teaches graduate level courses in Social Marketing, Focus Group Methods, Research Methods, and Media Skills. And for the second year in a row, Suzanne will teach a course on ” m-Health: Mobile Communication for Public Health”, in the Swiss School of Public Health+ Summer School this August in Lugano.

Analysis of Medicine Entitlement Programs for NCDs in the Philippines.

Author(s) Raoul Bermejo1, Beverly Lorraine Ho2, Wim Van Damme3
Affiliation(s) 1Department of Public Health, Institute of Tropical Medicine -Antwerp, Manila, Philippines, 2Health Unit, Philippine Institute of Development Studies, Manila, Philippines, 3Department of Public Health, Institute of Tropical Medicine -Antwerp, Antwerp, Belgium.
Country - ies of focus Philippines
Relevant to the conference tracks Governance and Policies
Summary In response to rising non-communicable disease prevalence and access to medicines challenges for the worst-off, the national government has launched three medicines access programs. Data were collected from informant interviews, site visits and document reviews. These were analyzed by first creating a chronology of events. Then, using a health policy framework, strategies and actions used along with the results were examined. Findings revealed that the rapid roll out of the NCD access programs exhibited strong political commitment towards UHC. However, weak policy processes have failed to ensure equitable access to quality and cost-effective medicines and implementation success.
Background As more Filipinos continue to be exposed to non-communicable disease risk factors such as tobacco and alcohol use, unhealthy diets and physical inactivity, prevalence for hypertension and diabetes mellitus have risen to 21% and 7.7 % respectively in 2008, and are expected to increase further. Cardiovascular disease and diabetes, along with cancer and chronic respiratory disease account for 57% of total deaths during the same year. According to the National Health Accounts, 52.7% of health expenditures are out-of-pocket. Of these, pharmaceuticals – accounting for 65.75% of household spending – are the single largest item of health care expenditures for households. Republic Act 9502, a law providing for cheaper and quality medicines was enacted in 2009.The Department of Health’s National Center for Pharmaceutical Access and Management launched three medicine access programs, namely DOH Complete Treatment Pack (ComPack), Valsartan (VAP) and Insulin Access Programs (IAP). ComPack provides complete (monthly) treatment regimens at no cost to the poorest families identified under the NHTS who are diagnosed to have diabetes and hypertension. VAP and IAP make available patent-protected Valsartan and Insulin at 60% lower cost than market prices.
Objectives The paper aims to document the policy process of three NCD medicine acces programs in the Philippines using a health policy analytical framework. Specifically, the paper seeks to understand the interaction of strategies that were employed and the factors that contributed greatly to policy advancement.
Methodology A qualitative, case study methodology using an in-depth longitudinal, prospective examination of events was employed for each of the three programs. Primary and secondary data were collected from (1) interviews with key policy and programme stakeholders; (2) visits to programme implementation sites; and (3) review of government documents, development partner reports, meeting records, conference proceedings and media clips. Representatives from government, academic institutions, nongovernment organizations, multilateral and bilateral agencies were interviewed. The interview guide reflected the three themes of emergence, formulation and implementation as described in the analytical framework by Lemieux (2002). A chronology of events was developed and process tracing was conducted. Triangulation of multiple data sources and discussion/verification with key actors supported interpretation and minimized bias.
Results Emergence: Our analysis shows that the following were critical in moving the access programs forward: (1) political commitment to achieve Universal Health Coverage by 2016, (2) availability of national health budget, (3) strong NCD policy community and access to medicines alliances, (4) increasing focus for the worst-off population and (5) strong industry lobbying.Formulation: The policy unit responsible for the programs was operational for less than 3 years when the policies were conceptualized and launched, and did not receive full technical support as was required. A relatively participative process was undertaken to define the contents but there was minimal integration into the health system.Implementation: Full subsidy of $15 million/annum and $400,000 are allocated for the ComPack and VAP. IAP has no subsidy since it is procured on a supply now-pay later (or consignment scheme). Information activities, implementation and evaluation support were constrained for all three programs largely due to funding limitations. The non-uniformity of information across health workers and patients resulted in a varied application of the policy in different implementation sites. Implementation was compromised by immediate national roll-out and devolved set-up for ComPack and the limited access sites for IAP and VAP. Availability of an efficient means for monitoring and responding to stock-outs remained a major challenge. To date, no plans for program evaluation have been articulated. IAP and VAP were also unable to address access challenges especially for the worst-off.
Conclusion The rapid roll out of the NCD access programs exhibit strong political commitment towards UHC. However, weak policy processes have failed to ensure equitable access to quality and cost-effective medicines and implementation success. Findings indicate that that rapid rollout of access to medicines programs is possible only if strategies employed are purposeful and contextually sensitive. Favorable conditions for the emergence of a policy may not always exist but can be created.

An Integrated Approach to Management of Diabetes and Hypertension in Western Kenya

Author(s) Simon Manyara1, Jemima Kamano2, Diama Menya3, Jeremiah Laktabai4, Benjamin Andama5, Evans Tenge6, FlorenceSituma7, SonakPastakia8
Affiliation(s) 1Pharmacy, Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya, 2Department of Medicine, Moi Teaching and Referral Hospital, Eldoret, Kenya, 3Epidemiology and Nutrition, School of Public Health, Moi University, Eldoret, Kenya, 4Family Medicine, Moi University, Webuye,Kenya, 5Family Preservation Initiative, Academic Model Providing Access to Medicines, Eldoret, Kenya, 6Family Preservation Initiative, Academic Model Providing Access To Healthcare, Eldoret, Kenya, 7Home Glucose Monitoring, Webuye District Hospital, Webuye, Kenya, 8Purdue University College of Pharmacy, Purdue University, Eldoret, Kenya
Country - ies of focus Kenya
Relevant to the conference tracks Chronic Diseases
Summary This pilot project seeks to establish whether the provision of intensive, self and peer management trainings to patients combined with the integration of income generating incentives leads to enhanced diabetes and hypertension control for resource-constrained patients in rural western Kenya. Patients are placed into peer support groups where they receive group care and are trained on various aspects of diabetes and hypertension self-care. These groups also double as microfinance groups that offer capital to patients to start up income generating activities. The groups are further incentivised to compete against each other based on both clinical and non clinical parameters.
What challenges does your project address and why is it of importance? Developing countries are facing an increasing burden of non communicable diseases (NCDs). While there has been increased emphasis in addressing communicable diseases by the international community, the vast majority of NCDs have been neglected, leaving patients with very poor outcomes and limited prospects for a healthy life. Due to their chronic nature, NCDs strain the already scarce resources of healthcare systems and families in resource constrained settings. Furthermore, NCDs are no longer associated with the wealthy or elderly, for they also affect poorer rural dwellers and younger members of the society who are expected to be economically productive. This adversely affects economic development in these populations, further propagating the vicious cycle of poverty. The prevalence of diabetes in Kenya is 4.7%, while that of hypertension has been reported to be as high as 23.7% in some urban settings. Patients with chronic diseases in Kenya face several barriers to care, including lack of access to essential services and inadequate information. This project uses a holistic approach which directly addresses barriers related to the socioeconomic status of patients with diabetes and hypertension, while encouraging positive health seeking behaviors.
How have you addressed these challenges? Do you see a solution? Bridging Income Generation with Provision of Incentives for Care (BIGPIC) uses an integrated approach that capitalizes and builds on the AMPATH’s (Academic Model Providing Access To Healthcare) existing infrastructure and years of experience in managing patients with HIV/AIDS throughout western Kenya. We focus on the following points of intervention:
1) Peer Groups.
Following community-based screening, positively diagnosed patients are placed into peer groups where they receive intensive training on self-management strategies for diabetes and/ or hypertension. They are given targets for their management which will be evaluated upon completion of the pilot. Targets will comprise of both process metrics such as clinic attendance, medication refills, fulfillment of ordered tests and clinical outcome metrics including blood pressure and sugar control. Patients receive group care and are provided with essential services like clinical consultations, selected portable laboratory tests and medication at affordable prices. They are expected to pay for each service and all the money collected is used to restock supplies.
2) Incentivization.
Patients are instructed on the incentives that can be earned through participation in this program. Their care is evaluated after 6 months to document the progression of their glucose and/or blood pressure control using standardized laboratory assessments. They receive points based on the set targets and these points can be used to earn various predetermined rewards. Incentives are awarded at two levels of participation – the group level where the top three groups with the most improved outcomes will receive rewards, and at the individual level where each participant attaining pre-set goals receives a reward.
3) Economic empowerment
The economic component of the project is facilitated by the Family Preservation Initiative (FPI), which is AMPATH’S income generation program. This will be achieved by the incorporation of a micro finance component which provides interest-bearing loans to members while offering a limited form of financial insurance. Participants mobilize and manage their own savings. They can therefore access affordable loans and get advice from FPI agribusiness officers on sustainable income generating activities. BIGPIC combines the socioeconomic benefits of FPI activities with the care strategy utilized by our diabetes program to synergistically enhance the outcomes and retention in both programs.
How do you know whether you have made a difference? While AMPATH has enjoyed immense success in the management of patients with both communicable and non communicable diseases, a lot of effort still needs to be put into retention of new patients to care. Data from the chronic disease management team shows that only 30% of patients who screened positive for diabetes and hypertension ever returned to a health facility for care. Preliminary data from this project shows that out of the 902 patients that were screened, 157 patients screened positive for either diabetes or hypertension. Of those that screened positive, 67.5% (n=106) came back to the health centre for confirmatory screening. Currently, 70.3% (n=71) of all those who confirmed positive for diabetes or hypertension are enrolled into the peer groups and are receiving care. The pilot will be completed in December and the final results will be presented at the conference
Have you or the project mobilized others and if so, who, why and how? This project draws expertise from a multidisciplinary team and intricately incorporates several aspects of patient care. The chronic disease management team provides the necessary platform for the management of diabetes and hypertension, from facilitation of screening activities to capacity building through staff training at health facilities. The Primary Healthcare team at AMPATH provides valuable insights into community strategies and engagement both at the macro and micro levels. One of the key approaches has been the use of community health workers (CHWs) for the purposes of finding patients, linking them to health facilities and raising awareness on chronic diseases within the community. The peer groups are also led by the CHWs who we train intensively on diabetes and hypertension self-care and on the operations of the GISE groups. The project taps into AMPATH’s Family Preservation Initiative’s GISE project. Through the microfinance groups, we strive to empower our patients economically through access to capital and giving them advice on viable business ventures. These microfinance groups have been shown to have high retention rates of its members, an outcome that we hope to achieve by incorporating the microfinance element into healthcare. This project is further strengthened by AMPATH’s pharmacy team which has a revolving fund pharmacy project that provides quality medicines to its patients at affordable prices. The revolving fund pharmacy works by procuring quality controlled medication in bulk and availing it to patients at a price that is almost at cost. Through this project, we have been able to provide quality, low cost essential antidiabetic and antihypertensive medicines to our patients. The biggest piece of the puzzle is the government health management team which is responsible for the implementation of all health initiatives within a district. This team facilitates all our activities on the ground. Part of the activities that we engage in include capacity building of the existing infrastructure by carrying out refresher courses on good practices in the management of diabetes and hypertension and mentoring the staff in the lower level facilities like dispensaries and health centres.
When your donor funding runs out how will your idea continue to live? BIGPIC offers a sustainable means of ensuring access to healthcare while at the same time promoting economic empowerment, leading to a healthier, more productive labor force. The project is modeled around the existing healthcare system and infrastructure in Kenya. Care for diabetes and hypertension at the facility level is enhanced through capacity building by training of the existing government healthcare workers. This is followed by close mentorship by the chronic disease management team at AMPATH, ensuring that patients can access quality care even in our absence. The microfinance groups have been shown to have a high retention rate of its members, and we believe that this model will maintain the members of the peer groups long after completion of the initial six months of our involvement. This will promote self-care within the members hence leading to improved patient outcomes. Patients are also empowered economically through these groups where they can access capital from their own savings. The groups create their own constitutions that guide their operations, and we only facilitate income generation through our agribusiness advisors. This ensures that they own the project and that the groups can continue independent of our support. Provision of drugs through the revolving fund pharmacy ensures continuity of drug supply since patients pay for the drugs and the money collected is solely used to purchase more drugs. Furthermore, antihypertensive and antidiabetic medicines are not supplied to dispensaries and health centres and the provision of these drugs at this level ensures accessibility while promoting the use of lower level facilities, with only complicated cases being referred to higher level facilities. Patients are expected to pay for every service that is provided through group care. The money collected from this model of care makes its continuity sustainable. The information provided to the community through the CHWs and the patients participating in the project will also go a long way in preventing NCDs by averting common risk factors such as poor diets, physical inactivity, unhealthy use of alcohol and cigarette smoking. This project therefore draws its strengths from a multidisciplinary team and integrates proven, sustainable interventions to achieve a holistic care model for diabetes and hypertension within a resource-constrained setting.

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

Cardiovascular Risk Factors among adolescents of Nepalgunj Municipality in Nepal.

Author(s) Manita Pyakurel 1, Anup Ghimire 2, Paras Pokharel 3.
Affiliation(s) 1Community medicine, Nepalgunj Medical College, Kathmandu, Nepal, 2School of public health and community medicine, B.P.Koirala Institute of Health and sciences, Dharan, Nepal, 3School of public health and community medicine, B.P.Koirala Institute of Health and Sciences, Dharan, Nepal 4.
Country - ies of focus Nepal
Relevant to the conference tracks Education and Research
Summary The aim of this study was to find out the prevalent risk factors of CVD and the association of Metabolic syndrome (MS) with behavioral risk factors (BRF).  A cross sectional study was done among 736 school going adolescents. A Systematic random sampling was done to select the sampling unit. CVD risk factors were assessed by World Health Organization (WHO) STEPwise approach. MS was defined based on National Cholesterol Education Programme (NCEP, 2003) criteria. Chi square test of association and multivariate logistic regression were applied. The prevalence of MS was 23(3.1%). Unprotective HDL and increased TG were the most common metabolic risk factors.
Background Over the centuries we have experienced great transitions in social, economic structures and home environments leading to the shift from agricultural and rural societies to industrial urban societies. These transitions have resulted in major changes in physical activity, eating habits and other lifestyle factors. We now face the rise of non communicable diseases (NCD) in addition to the remaining issues of communicable diseases. As a result low and middle income countries are facing a double burden of the modern risks of NCD. [1]
CVD is responsible for 16.7 million (29.2%) of total global deaths. CVD accounts for approximately 80% of deaths in low and middle income countries. [2] India predicts 64 million cases of CVD in year 2015. [3] In Nepal hypertension has the highest prevalence among the CVD at the tertiary level. [4] Cardiovascular risk factors vary with increasing age, gender, and ethnicity. Behavioral, genetic and metabolic risk factors are established risk factors. [3] In Dharan municipality prevalence of CHD is 57 per 1000. [5] Major behavioral risk factors in Nepal are tobacco smoking 23.3%, physical inactivity 14.2%, high blood sugar 8.4% and obesity 9.1%.[6,7]  Adolescence is the appropriate age range for tracking CVD as the evidence of increased chance of atherosclerosis occurrence increases with age and unhealthy behavioral activities. [8-11]
Objectives General objective.
To determine the prevalence of cardiovascular risk factors among the school going adolescents of the Nepalgunj municipality.Specific objectives:
1. To find out the prevalence of common risk factors of cardiovascular disease among the adolescents.
2. To evaluate the statistical relationship of cardiovascular risk level with sociodemographic variables & lifestyle.Research question.
What is the prevalence of risk factors of cardiovascular disease among the school going adolescents of age 10-19 years?
Methodology 2.1. Study population
A cross sectional study was conducted among a total of 736 adolescents of public and private schools of Nepalgunj municipality of Banke district Nepal from September 2012 to February 2013. Ethical approval was obtained from the institutional review board of B.P.Koirala institute of health sciences. The study was conducted with the financial and logistic support from Nepalgunj medical college. Data collection was done using the STEPS questionnaire of WHO.
2.2. Anthropometric measurements.
Blood pressure was measured with standard mercury sphygmomanometer with adequate cuff size and systolic blood pressure was taken by first heart sound (Kortokoff phase I). Diastolic pressure was recorded at the level when sound disappeared (Kortokoff phase V). Two reading were taken on the right arm at least 5 minutes apart. Before measuring blood pressure the respondent rested for at least 5 minutes or as required. This excluded those who had smoked within the last 30 minutes.
Waist circumference was measured using a nonelastic tape to the nearest 0.1 cm over the unclothed abdomen at smallest diameter between coastal margin & iliac crest. Tape measure was horizontal. Respondent was relaxed with arms held loosely by the side. Measurement was taken at the end of normal breath. Both arterial hypertension and abdominal obesity was categorized according to NCEP (2003) criteria.
2.3. Biochemical tests.
A venous blood sample was collected after fasting 12 hours to assess the serum levels of triglyceride (TG), total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C) and fasting blood sugars were collected and brought to biochemistry lab of Nepalgunj medical college. Automated biochemistry analyzer was used to analyze the lipids.
2.4. Diagnostic criteria.
Among the behavioral risk factors dichotomous variable dietary habit was defined as unhealthy for less than 22 minimum score (sum of salt score, frequency of: fruit intake, vegetable intake, food consumed outside). Physical activity was categorized as inactivity for less than minimum score of 77 (sum of moderate / heavy vigorous exercise and sleep). MS was categorized as positive and negative according to NCEP criteria (2003).
Results Analysis was done among 736 adolescents(331 boys,405 girls). The mean age of the study population was 15.22 ±1.79. Among the behavioral risk factors, adolescents who consumed tobacco were 62(8.4%) and alcohol 51(6.9%). Adolescents with unhealthy dietary habit were 726 (98.6%). Physical inactivity was present in 591(80.3%). Also 345 (46.9%) reported stress at any point of time. Among the genetic factors, family history of chronic diseases were present among 547(74.3%) and 1.9% were diagnosed for congenital heart disease. MS was present among 23(3.1%) with 1.3% among male and 1.7% among female.
Baseline characteristics of metabolic risk factors shows mean SBP, DBP of 110.6 ±12.3, 70.3±10.6 and 104.6±11.7, 66.1± 10 mm of Hg among male and female respectively. Level of MS was categorized in 5 levels based on clustering of the risk factors according to sex distribution, described in table no.1, 2 and 3.Bivariate analysis shows no significant association between age, sex, ethnicity, religion and MS. Significant association of 3.9times increased odds of, (95% CI: 1.7-9.2) was established between positive family history and MS as compared with reference category of negative family history.
Multivariate analysis among male adolescents shows positive family history have 10.85 increased odds of (95% CI: 2.42-48.61) MS as compared to its counterpart negative family history. Among the female adolescents non refined oil consumption showed 8.24 increased odds of (95% CI =1.05-64.78) MS as compared to the refined oil consumers. Whereas non stressful adolescents have 4.22 increased odds of (95% CI=1.08-16.4) MS compared to the stressful.
Conclusion From our findings the most prevalent behavioral risk factors were consumption of non refined oil, unhealthy dietary habit, physical inactivity and stress. Among the genetic risk factors, prevalence of 1.9% CHD and positive association of family history with MS were alarming. More than ¾ of adolescents have at least one risk factor of MS. Among the components of MS, dyslipidemia was the most common risk factor affecting the adolescents. Males with positive family history and a non refined oil consumer and non stressed females were important risk factors for identifying adolescents at risk for later CVD onset. The result suggests that preventive measures including consumption of refined oil may be warranted for these adolescents. In conclusion, the presence of behavioral and metabolic risk factors for CVD is an important health problem among the adolescents of Nepalgunj municipality. There is a need for a national programme to control cardiovascular risk factors among these adolescents.

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.

The Social and Economic Status of Patients Attending an HIV/AIDS Treatment Centre in Yaounde, Cameroon

Author(s): D. M. Njamnshi*1, J. Y. Fonsah2, F. N. Yepnjio2, C. Kouanfack1, A. K. Njamnshi2
Affiliation(s): 1HIV Day Care Centre, 2Neurology, Central Hospital Yaounde, Cameroon
Keywords: HIV/AIDS, socio-economic status, ARV, Cameroon.
Background:

HIV/AIDS is a pandemic worldwide especially in sub-Saharan Africa. Cameroon had 590,000 persons with HIV/AIDS with some 46,000 deaths / year in 2005*. Social and economic factors have been associated with HIV transmission and morbidity. Poverty and economic inequality have clearly been associated with HIV transmission*. Few studies have examined this association in Cameroon. We hypothesized that the social and economic status of patients affects their present HIV serological status may affect access to Anti-Retroviral (ARV) drugs, compliance and adherence in Yaounde, Cameroon. At time of study, ARV regimens cost between 3000 and 7000 Francs CFA.

Summary/Objectives:

To examine possible associations between socio-economic factors and HIV seropositivity and access to ARV treatment in our context. The design was a cross-sectional descriptive study in a tertiary health facility. Patients who signed a consent form were interviewed at the Day-Care Hospital, Yaoundé Central Hospital between October and December 2006. Administrative authorization and ethical clearance for research were obtained from the Ministry of Public Health and the National Ethics Committee respectively.

Results:

The female to male ratio was 2.4:1 %, n=94. The mean age of the sample was 37.3 ± 8.9 years. The mean age of the males was 41.52 ± 8.99 years; that of females was 35.5 ± 8.38 years, p=0.003. Concerning marital status, 50 (54.3 %) of the patients were currently married while 21.7 % were single. Fifteen (16.3 %) were widowed and 7 (7.6%) were divorced. Of those once married, 76.2 % were involved in monogamous relationships and 23.8 % were in polygamous relationships. For the patients with stable relationships, their partners were mainly housewives (25.4 %), farmers (10.2 %), or uniformed men/women (10.2 %). A high percentage of the whole sample consisted of housewives (22.8 %), followed by individuals in business (17.4%) and then the unemployed (14.1 %). Half of the patients (50.0 %) had up to secondary school level education, while 38.0 % had primary education and 9.8 % had attended university; 2.2 % never had any formal education. Considering risk behaviour assessment, all the respondents were sexually active, 65.8 % having multiple sexual partners. Only 12.0% reported regular use of condom against 25.0 % that never used one (p=0.007). Marital status did not seem to affect condom use significantly. Almost half (42.4 %) of the patients were occasional consumers of alcohol. Alcohol consumption was significantly associated with the availability of a stable source of income; p = 0.007. We did not find any IV drug users or homosexuals in the sample. More than half (55.4 %) of the respondents had a stable source of income. Up to 25.5 % of these lived on < 10,000 FCFA per month; 23.5 % declared an income of > 100,000 FCFA/month, and 5.9 % an income between 50,000 and 100,000 FCFA. ARV treatment was afforded by 52.2 % of patients themselves while 47.8 % received theirs through the help of family members (30.4 %), husband (9.8 %), NGOs (7.6 %).

Lessons learned:

HIV transmission in our sample is essentially through heterosexual behaviour, favoured by multiple sexual partners and very little protection (condom use), thus the need for more sensitisation. Less than half of our sample could not afford ARV treatment by themselves and this could affect compliance and adherence to therapy, so the need for universal access to ARVs.

Vulnerable Populations and Inequalities in Health: The Case of Marginalized Women with Substance Abuse Problems

Author(s): M. P. Romero1
Affiliation(s): 1Researcher on medical sciences E. Direction of epidemiological and psychosocial research, National Institute of Psychiatry, Mexico city, Mexico
Keywords:

Vulnerable population, women, substance abuse, equity

Background: Interest in health inequalities has grown in recent years. The World Health Organization (WHO) defines them as health variations that are unnecessary, avoidable and unfair (Whitehead M, Dahall G, 2007). These inequalities are also gendered. Gender is a concept that incorporates the social factors associated with men and women’s different patterns of socialization, which in turn has to do with family roles, work expectations, types of occupation and social culture which also affect the process of health and illness. In this work we use the concept of gender quoting Ettore (2002): ‘gender is a process and an institution…As a process, gender is a part of all human interactions. Gender shapes the meaning of “female” and “male” and “masculinity” and “femininity” on cultural, political and economical levels. As an institution, gender is a part of culture just like other components of culture such as symbols, language, mores, norms, values and so on. Gender is a “stable” form of structured inequality and it is embedded in culture’ (p. 329). When women experience the damaging effects of gender whether as a social process or an institution, women are at a greater disadvantage because ‘masculinist’ (male privileging) more than gender-sensitive structures and paternalistic epistemologies predominate. In addition to gender inequalities, there are also social and economic inequalities that give rise to marginalized groups. Therefore, for vulnerable populations, ensuring healthcare coverage an access to good-quality, appropriate public and private sector services is an ongoing a challenging proposition (Ferguson 2007). Type of study: A non-experimental, descriptive, ex-post facto cross sectional study was undertaken in two women’s prison in Mexico city. A non probabilistic sample of 213 women was selected, with the following inclusion criteria: current or sometime consumers of alcohol, tobacco and drugs, aged between 18 and 65 who can read and write.
Summary/Objectives:

The aim of this paper is to discuss from the theoretical framework of gender perspective and vulnerable population’s literature, the burden of disease of substance abuse in vulnerable women, specifically data from a research with minor delinquents and women in prison.

Results:

Among the interviewed women 14.6% have lived in a shelter or NGO before the prison and 39.5% have lived in the street. The third part (30.5%) ran away from home at least once while being children and 21.6% live with persons different from their parents. On the day they committed the offence 41.8% were under the effects of drugs and 18.8% on alcohol. Among the drugs they used while or before committing the crime, 26.85 % had used cocaine. The most commonly reported crime among the interviewees was theft (51.6%) in different forms (non-specific/simple, qualified, aggravated, non-specified, burglary) followed by drug related offences (possession, traffic) 23.5 % and the third crime was homicide (8.5%). According to their response 43.7% reported having been in a correctional facility before.

Lessons learned:

Prison is an environment with special difficulty in the promotion of health. At the individual level, prison takes away autonomy and may inhibit or damage self-esteem. Common problems include bullying, mobbing and boredom, and social exclusion on discharge may be worsened as family ties are stressed by separation. However, imprisonment is also a unique opportunity for all aspects of health promotion, health education and disease prevention. Vulnerable groups as the women in prison and minor offenders are disadvantaged groups who would normally be hard to reach. It is the prison, therefore a prime opportunity to address inequality in health by means of specific health interventions as well as measures that influence the wider determinants of health (Haton P., 2007).

Confronting Homelessness as a Human Rights Violation for Persons with Mental Disorders

Author(s):  M. Moses1
Affiliation(s): 1Post Graduate, Faculty of Law, Makerere University, Kampala, Uganda
Keywords: Homelessness, mental disorders, human rights
Background:

The basic idea of human rights is construed as the intrinsic dignity and worth of an individual. Dignity and worth of an individual envisages provision of services to an individual such as housing. Typically, a discourse about homelessness and human rights focuses on the right to housing. Violation of this right to housing is in most cases caused by the shortage of affordable housing facilities, poverty, low wage work insufficient to pay for basic living expenses, and the lack of services to help people overcome personal challenges such as mental and physical health problems and alcohol and substance abuse. This is a topic of crucial importance, particularly in light of the lack of appropriate, adequate and affordable housing a cross the world especially in the developing countries. Relatively there has been little discussion on the provision of housing to persons with mental disabilities especially in the developing world. This discussion imposes an obligation on the states to immediately ensure that all persons with mental disabilities are provided with housing facilities to the maximum of its available resources and to progressively realize such persons’ economic, social and cultural rights. As will be discussed in this paper, homelessness is in itself a human rights violation and that it constitutes an infraction of such fundamental human rights and dignities.

Summary/Objectives:

A home, in addition to being a basic right, is in many places the crucial limiting factor in the process of deinstitutionalization and psychiatric reform. Everybody needs decent home. The need for psychiatric beds for people with mental disorders is beyond question. This paper examines the elements of international human rights law directly linked to persons with mental disabilities. It makes a discussion of the right to adequate accommodation and shows how respect for human rights can ensure eradication of homelessness in persons with mental disabilities. It further recognizes that homelessness is a violation of fundamental human rights and freedoms. It recognizes that viewing homelessness as a human rights violation is of significant normative value and legal import in ensuring that homelessness in persons with mental disabilities is controlled

Results:

The study found that persons with mental disabilities are a special kind of group that need protection since they are unable to work and provide fro themselves. A home in addition to being a basic right is in most cases the limiting factor for the realisation of other rights of persons with mental disabilities. It also found that the United Nations recognizes the need for increased international human rights, protections for people with mental and physical disabilities and as a result several international human rights instruments have provisions with implications on the rights of persons with mental disabilities.

Lessons learned: That using human rights discourse to address the issue of homelessness, empowers people experiencing homelessness themselves and can be a vital tool for primary prevention of homeless in people with mental disorders. It also challenges us to recognize that all is not well and that we must do better to end homelessness especially in persons with mental disabilities. Thus mental disability person’s rights activists should always invoke the human rights approach in the fight against homelessness in mental disabled persons. This approach does not only protect the mental disabled persons but also ensures public health as threats of harm to the public and property by the mental disabled persons are always minimized.