Geneva Health Forum Archive

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

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

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


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


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

Lessons learned:

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

Task Shifting for Integrated Management of Hypertension and Diabetes in Rural Cameroon: An Observational Cohort Assessment at Two Years

Author(s): N. D. Labhardt*1, J. Balo2, M. Ndam3, E. Manga3
Affiliation(s): 1Swiss Tropical Institute, University of Basel, Basel, Switzerland, 2District Hospital Mbankomo, 3District Hospital Mfou, Ministry of Public Health of Cameroon, Mfou, Cameroon
Keywords: Non-communicable chronic diseases, Task shifting, Integrated care, Non-physician clinicians, Diabetes, Hypertension

Sub Saharan Africa (SSA) faces a looming epidemic of arterial hypertension and diabetes for which most countries are not prepared. We tested in eight rural Cameroonian districts a model of integrated care by task shifting of the management of hypertension and diabetes from hospitals to facilities led by non-physician clinicians (NPCs).


After a preliminary survey in 75 peripheral health centres, 69 were subsequently trained and equipped for prevention, diagnosis and treatment of hypertension and type 2 diabetes. Two years later the effectiveness of the programme was assessed by the status of equipment and drugs in formerly equipped facilities (1), knowledge among trained NPCs, assessed by a multiple-choice questionnaire (2), number of newly detected and followed patients (3) and trend in blood pressure (BP) and fasting plasma glucose (FPG) among treated patients (4).


(1): At baseline only 49 (65%) of the 75 health centres were equipped to measure BP and 11 (15%) to measure FPG. Twenty (27%) disposed of an anti-hypertensive and nine (12%) of an anti-diabetic drug. Two years after training and equipment of NPCs, all had still a functional sphygmomanometer and stethoscope, 96% an antihypertensive drug on stock, 70% had a functional glucose meter and 72% an oral anti-diabetic drug on stock. (2): Knowledge about hypertension among nurses was poor before training (on average 41% of correct answers per question), improved dramatically after the course and remained high at two-years (on average 80% of correct answers) (p<0.001). (3): Of the 796 newly detected patients, 2579 visits of 222 patient-years were recorded. Of all patients 562 (70.6%) were lost to follow-up at the time data were collected. Of these, most (75%) were lost during the first three months. (4): Among hypertensive patients with ≥ 2 visits (n=438), systolic BP decreased by 23.5mmHg (CI95%: 20.5-26.6; p<0.0001) and diastolic BP by 12.5mmHg (10.6-14.5; p<0.0001). Among diabetic patients with ≥2 visits (n=79) FPG decreased by 3.4mmol/l (1.8-5.1; p<0.001).
In conclusion, integrated management of hypertension and diabetes by nurses in general NPC facilities in rural settings with limited resources is feasible on a district scale. NPCs were successfully trained and equipped and their patients showed a good treatment response. However, a relatively low case-detection rate per NPC and a very low retention rate in the program at two years severely limit the effectiveness.

GHF2008 – PS01 – Management of Chronic Disease I: A Multistakeholder Approach

Session Outline

Parallel session PS01, Monday, May 26 2008, 11:00-12:30, Room 4
Chair(s): Ala Alwan, Assistant Director-General, Non-Communicable Diseases and Mental Health, WHO, Switzerland
Role of an International Federation in Promoting Chronic Disease Prevention
Janet Voûte, Chief Executive Officer, World Heart Federation, Switzerland 
Centres of Excellence in Developing Countries to Counter Chronic Disease
Richard Smith, Director, Ovations / National, Heart, Lung and Blood Institute Chronic Disease Initiative, UK
Reform of Health Systems for Chronic Diseases in Pakistan
Sania Nishtar, Founder and President, Heartfile, Pakistan

Session Documents

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Session Report

Submitted by: Reem Ibrahim (ICVolunteers)

Every year, World Heart Days aims to rise awarness about heart diseases. Image: poster for World Heart Day 2006

With the passing of the World Health Assembly resolution and endorsement, it is the perfect time to address the implementation and strategy objectives for non-communicable disease (NCD) prevention and control. NCDs are responsible for approximately 60 percent of all deaths globally, with figures estimated to increase. A substantial proportion of major chronic diseases (CD), specifically cardiovascular disease (CVD), respiratory diseases, cancer and diabetes can be prevented.

The key objective is to link global socio-economic development and national policies in sectors to raise priority and awareness, increase focus on strengthening national policies, promote interventions, develop research agendas and partnerships, and monitor global NCD. 40 percent of cancer is preventable. 80 percent of heart disease, strokes, and type II diabetes are preventable. 100 percent action is needed: now.

The Chair, Ala Adwan, World Health Organization Assistant Director-General for Non-communicable Diseases and Mental Health Department opened the session by summarizing the key objectives for integrating NCD into the global-health system. Mr. Adwan then introduced the three speakers: Janet Voûte, Chief Executive Officer at the World Heart Federation (WHF), Switzerland; Richard Smith, Director of Ovations/National, Heart, Lung and Blood Institute Chronic Disease Initiative, United Kingdom; and Sania Nishtar, Founder and President of Heartfile, Pakistan.

Janet Voûte highlighted the role a federation can take in working as a complimentary organization towards improving prevention of global heart disease. The WHO Action plan for NCD, Grand Challenges Partnerships is a starting point for change, but more action is needed. NGOs and federations are perfectly positioned to voice concerns regarding health initiatives, such as the need to include NCD prevention and control in the United Nations Millennium Development Goals (MDGs). Key aspects include: raising awareness, modifying risk factors, re-orienting health systems, strengthening national policies and monitoring progress.

Ms. Voûte emphasized the pertinence of mobilized member networks consisting of continental members and members in national societies to complement WHO efforts on prevention and control. "By mobilizing member networks, a federation can be a strong partner in the control of chronic disease". She explicitly addressed the essential factors for progress: awareness, advocacy, sharing of scientific knowledge and demonstration projects. For example, the World Heart Day is one aspect for mobilizing networks to increase awareness: each year, a chosen theme focuses on risk factors of NCDs, in order to induce change in our daily lives. Efficient use of all available resources and tools is vital to spreading key health messages.

The WHF leadership can be a model for other federations to improve existing tools and strategies, to help mobilize members, to work in partnerships and monitor and evaluate progress.

Richard Smith expanded on the call for immediate action for the prevention and control of LCDs, stating that in 2005, thirty-five million people died from chronic disease. Yet, he noted, only minimum available health-funding is used to treat them. A higher burden is evident in low-middle income countries, and a rising prevalence of death in younger generations has also been registered. Nonetheless, a number of cost-effective intervention strategies have been established that can help pave the way to prevention.

Mr. Smith continued on the topic of commitment. Partnerships must be created with the developing countries to build capacity and raise international consciousness. The partnership of Ovations and the National Heart, Lung and Blood Institute (NHLBI) deploys a proactive approach to work effectively towards meeting current objectives. Each of these organizations contributes fifteen million dollars as funding to eight "Centers of Excellence" in the chronic disease initiative. These centers, created to promote change in an entire community, are responsible for research, advocacy, policy development, community intervention, providing guidelines for non-doctors, disease management, as well as fostering primary and secondary prevention strategies. They have also developed tools for estimating chronic disease risk in low income countries.

To correlate the vital topics concerning NCD prevention and control, Sania Nishtar wrapped up the session with three main ideas:

  • Multi-stakeholder response to management
  • Pakistan's response
  • The health system

Ms. Nishtar stated that a comprehensive consolidated global response is needed. We know that 80 percent of NCD cases occur in low-middle income countries.

She drew attention to the significant development of the World Bank on committing resources to NCDs and focusing on country assistance, and she applauded the initiatives by academia and industry. Global partnership for chronic disease control will bring the needed change into practice by, for example, setting standards; synchronizing multi-stakeholders; and assisting the developmental agreement of the WHO. Partnerships certainly can derive donor assistance and provide financial instruments that catalyze the reallocation of resources towards the social sectors.

Ms. Nishtar also highlighted Pakistan's response to NCD:

  • 0.6 percent of GDP is spent on health
  • The government agreement in 2003 to allocate resources to an action plan on NCD prevention and control
  • The establishment by the government of an action plan on disease surveillance with appropriate legislation

Various challenges do exist, however, and there is a fundamental need to strengthen the country's health system. Certain flaws in management have raised issues, such as data statistics gathering, connectivity, central reporting, the lack of adequate research mechanisms and the delivery of service. To promote a mainstream program of health within a country, it is vital to first strengthen the health system.

How to Improve Retention Rates in NCCD Programmes in Rural Africa: The TAHADIRA Trial

Author(s): N. D. Labhardt*1, J. Balo2, E. Manga3, M. Ndam4, B. Stoll5
Affiliation(s): 1Swiss Tropical Institute, University of Basel, Basel, Switzerland, 2District Hospital Mfou, Ministry of Public Health of Cameroon, Mbankomo, 3Ministry of Public Health, 4District Hospital Mfou, Ministry of Public Health of Cameroon, Mfou, Cameroon, 5Institute of Social and Preventive Medicine, Faculty of Medicine, Geneva, Switzerland
Keywords: Hypertension, diabetes, treatment adherence, treatment retention, non-communicable chronic diseases

Low retention rates and poor treatment adherence pose major challenges to programs for non-communicable chronic diseases (NCCD) in Africa. Monitoring data of a program that integrated management of arterial hypertension and diabetes into the primary health care of non-physician clinics (NPCs) in eight rural Cameroon districts reveal a one-year retention-rate below 50%. In order to improve the effectiveness of large NCCD-programs, efficient and easily replicable interventions to improve treatment adherence are urgently needed. The aim of this randomized trial is to compare two low-cost interventions on a NPC level in rural Cameroon to lower the attrition in the program.


Thirty three rural NPCs from four districts were randomly assigned into three groups: The control group requested a written and oral commitment from the patient to follow the treatment before the treatment start. Facilities of the intervention group A had additionally an active patient-tracing by community representatives. Intervention group B provided as an incentive for adherence one month of treatment for free every four completed months with good adherence.
At one patient-year we assess as the primary outcome the percentage of patients with a regular follow-up. Secondary outcome measures are: percentage of missed follow-up visits (i) trend in blood pressure among hypertensive patients (ii) and trend in fasting plasma glucose in diabetic patients (iii). The study is registered at (NCT00744458)


During a period of six months, the 33 NPC-clinics recruited 218 new, treatment-naïve patients. The average age was 60 years (inter quartile range: 51-68), 65% were female. Sixty eight percent had arterial hypertension alone, 18% arterial hypertension and impaired fasting glucose, 11% hypertension and diabetes and 9% diabetes alone.
In February 2010 the study will be closed and data collection performed. The primary and secondary outcome measures of this study will be presented at the Geneva Health Forum 2010. This will contribute to the discussion on how to improve the retention rate in NCCD programs in general and give specifically information on the evolution of hypertensive and diabetic patients who are followed by general NPCs in a rural primary health care setting in Cameroon.

The Mauritanian Model: An Effective Way to Improve Access to Mental Healthcare in Developing Countries

Author(s): Ahmed Ould Hamady1, Daniel A Gérard2, Osman Sall, Youssouf Ould Limame1
Affiliation(s): 1Ministry of Health, Mauritania, 2Chronic Diseases, Sanofi, France
1st country of focus: Mauritania
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Mauritania is a wide country of 1 million square kilometers mainly covered by desert, with 3 million inhabitants and only 3 psychiatrists. A pilot project designed to improve access to mental healthcare in the country was implemented in Nouadhibou city at the North West country border. In May 2009, 7 mental health clinics were opened in the city and surrounding areas. Thanks to the commitment of the medical staff and local NGOs, the treatment gap in schizophrenia was reduced by 38% in 2.5 years (from 93% to 58%) by running a strong awareness program and providing adapted, available, affordable medicines.
Background (max 200 words): Four mental disorders are in the top ten leading causes of disability (depression, bipolar disorders, schizophrenia, alcohol abuse) and the prevalence of main mental disorders is similar in developed and developing countries. Mental disorders are one of the leading contributors to the Global Burden of Diseases in Low- and Lower-Middle-Income countries yet only scarce resources are devoted to them.

A survey conducted in the general population of Nouakchott in 2003 indicated that 35% of the sample population had at least one mental disorder: anxiety: 20%, mood disorders: 19% and psychotic disorders: 2.4%.  Available mental health care systems are not aligned with needs in Mauritania.
Resources are mainly concentrated in the capital, Nouakchott: 3 outpatient psychiatric clinics, 1 Neuropsychiatric center and 1 psychiatric department in the Military Hospital and very few resources are accessible in the rest of the country.
In addition the survey highlighted the overlap between madness and mental disorders in the perception of the population who mainly believes that psychiatric symptoms are from magic or religious origin.
These data underline that improving mental health care in Mauritania requires a comprehensive process that combines: conducting awareness campaign; setting up services; getting funding; training healthcare professionals and making medicines accessible.
Objectives (max 100 words): The aim of this pilot project was :

(1) to test the feasibility of implementing one mental health clinic in each of the 13 Mauritanian provinces, working in a close network with the specialists from the Nouakchott neuropsychiatric center;
(2) to assess the impact of the project on the access to mental health care
(3) to learn from this experience for preparing an extension of the project to the rest of the country.
Methodology (max 400 words): This project is an action research project focused on access to healthcare for psychotic patients.

Intervention: inclusive approach bringing together:
  1. Advocacy towards decision makers (national, regional and local) so as to get their support for the implementation of the project;
  2. Training of health care professionals selected by the Head of the Regional Health Services;
  3. Regular supervision from specialists from the Nouakchott Neuropsychiatric center;
  4. Sustainable supply of quality affordable antipsychotics;
  5. Patients and families psycho-education sessions;
  6. Communities awareness initiatives on mental health issues;
Collected data: Number of patients included in the program, sex, age and diagnosis according to CIM 10. In addition, specifically for psychotic patients: estimation of the number of people with schizophrenia in the area; number of patients treated at baseline; conformity of the diagnosis made by the “investigator” and the diagnosis made by the specialist; Clinical Global Improvement, number of hospitalizations, questionnaire of integration in family and community; Drug Attitude Inventory-10 questionnaire; Involvement Evaluation Questionnaire
Results (max 400 words): An agreement was concluded between the Mauritania Ministry of Health represented by the Nouakchott Neuropsychiatric Center and Sanofi Access to Medicines in July 2008.

Nouadhibou (100,000 population), at the north border of the country, in front of the Canary islands, was selected as pilot site because of its population exposure to many risk factors for mental disorders: life style changes (from nomad life to settlement), transit place for illegal migration and drug trafficking…
The pilot program commenced in October 2008 with a meeting in the National Assembly and the endorsement of the national and local political and administrative decision makers. Between October 2008 and December 2010:
  • 37 health professionals from both public and private sectors were trained;
  • Outpatient mental health clinics were opened (since May 2009) in seven centers in the city (regional hospital, city hall dispensary, mine polyclinic, military infirmary, Moughataa dispensary) and in the surrounding areas (Boulenouar dispensary, Nouamghar dispensary).
  • Information tools were specifically designed for awareness campaigns and are used by several NGOs: posters, flipcharts and booklets.
  • More than 1000 people (patients, patient families, teachers, woman associations…) attended the different information meetings.
  • About 1200 patients are followed up in the mental health clinics (mainly for psychosis, depressive disorders, anxiety disorders and epilepsy)
  • In schizophrenia, with 342 new patients in 30 months, the treatment gap has decreased by 38% from 93% (May 2009) to 58.8% (December 2010).
The detailed results of the impact assessment will be presented.
Conclusion (max 400 words): This pilot program has a positive impact on the Nouadhibou population mental health. It indicates that access to care for patients with mental disorders can greatly be improved by a simple, assessable, replicable and scalable program. An agreement for the program extension to the whole country over 5 years through a partnership between the Mauritania Ministry of Health, the World Association for Social Psychiatry and Sanofi Access to Medicines was signed in June 2011. In addition to psychosis, the expanded program will also include other major mental disorders and epilepsy

GHF2012 – PL04 – Urban Planning, Development and Non-communicable Diseases: Innovative Experiences

Session Outline

Plenary session PL04, Thursday, April 19 2012, 17:45-19:15, Room 2
Chair(s): Françoise Barten, Radboud University Nijmegen Medical Centre, The Netherlands
Interdisciplinarity and Intersectoral Action in Urban Health: Getting the Equation Right"
Roderick J. Lawrence, Faculty of Social and Economic Sciences, University of Geneva, Geneva, Switzerland
Active Design: The Architects’ Role in the Public Health Debate
Frederic Bell, American Institute of Architects, New York, United States
Bangladesh Urban Health Network – The Pressure Group for Ensuring Health in Urban Bangladesh
Sohana Samrin Chowdhury, Bangladesh Urban Health Network, Dacca, Bangladesh
Road Traffic – A Global Health Threat
Nino Künzli, Swiss Tropical and Public Health Institute, Basel, Switzerland

Session Documents

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Session Video

Assessing the Impact of Medical Nutrition Therapy in Pregnancy Complicated by Diabetes in a Maternity Centre: Ibadan, Nigeria

Author(s): Hamidu Oluyedun1
Affiliation(s): 1Oyo State Hospital Management Board Secretariat, Ibadan, Nigeria
1st country of focus: Nigeria
Relevant to the conference theme: Communicable chronic diseases
Summary (max 100 words): The WHO regards diabetes as avicious silent killer diseases with its overall prevalence on the increase. This study aimed to reduce pregnancy mortality and faciliate better pregnancy outcomes. Two Hundred pregnant volunteers were chosen for the study which included the participation of various categories of Health Workers.  The study revealed a correlation between Health, Social and Educational levels of participants and the awareness of the dangers posed by diabetics to pregnancy. Training and the provision of specific information to volunteers resulted in better pregnancy outcomes.
Background (max 200 words): The WHO regards diabetes as one of the most vicious silent killer diseases with overall prevalence on the increase.   It is forecasted to afflict at least 200million people by 2012. In 1998 1.05million diabetics were reported in Nigeria, and  5% - 10% of Nigerians were believed to be diabetic in 2010. Type 2 diabetes is more widespread than type 1 diabetes and the prevalence of type 2 prevalence is increasing rapidly. Diabetes leads not only to immediate health symptoms but also long term complications such as cardiovascular and kidney disease. The  target levels for plasma glucose is >or = 6 but <7 mmol/l FPG and < 7.8mmol/l for PPG
Objectives (max 100 words): To help pregnant women with diabetes learn how to make lifestyle choices which enable them to achieve optimum metabolic control and prevent diabetic complications. To achieve and sustain acceptable body weight and prevent, delay or treat, complications. In addition to integrate diet, activity and pharmacological therapy were also the objectives.
Methodology (max 400 words): St. Peters Maternity Hospital, Aremo, Ibadan, a community based maternity centre, was chosen for this study. Volunteer pregnant women were selected for the study after consent forms were completed and the study was explained to the volunteers in languages they understood. In all, 200 pregnant women were involved in the study that spanned a 6 months period. Social History and Social Economic parameters were obtained from the pregnant women. The following diagnostics parameters were obtained from the recruits with the assistants of the Laboratory Scientists:- 1)Random blood glucose (RBG) – sample of blood taken at any time 2)Fasting blood glucose (FBG) – sample of blood obtained after a period of not eating or drinking for at least 8 hrs 3)Oral glucose tolerance test (OGTT) – a fasting blood glucose sample was initially taken, then a sweet drink is consumed and blood samples were then taken every 30mins for next 2hrs. The sample taken at 2hrs is the most important as it is linked to poor glycaemic control. Educational Intervention on nutrition were organised for the volunteers.
Results (max 400 words): Type 2 Diabetics was common in 25% of the volunters. The perception of the pregnant women was related to their educational bacground. Thereofore training on nutritional modificatios and exposure to the benefits of adequate diets from indigenous foods is important. The results showed that 50% of the diabetes in the pregnant women was controlled while the remaining 50% needed additional anti diabetics drugs for management. The pregnancy outcomes were better when compared to the pregnancy outcomes of the precedding 3years when the training and interventions were not in place.
Conclusion (max 400 words): The Millenium Development Goal 5 on Maternal Mortaltiy can be achieved with collaborative effort from all health workers. The result showed that good pregnancy outcomes are reliant on the collective efforts of all the health workers. The training should be increased and replicated in other health care facilities in the community.

Prenatal Genetic Diagnosis of Sickle Cell Disease: Preliminary Experiences: Cameroon

Author(s): Ambroise Wonkam1,2, Cedrik Ngongang Tekendo1, Huguette Zambo1 and Michael A. Morris3
Affiliation(s): 1Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon, 2Division of Human Genetics, University of Cape Town, Cape Town, South Africa, 3Service of Genetic Medicine, Geneva University Hospitals, Geneva, Switzerland
1st country of focus: Cameroon
Relevant to the conference theme: Medicines and diagnostics
Summary (max 100 words): The practice of prenatal genetic diagnosis of sickle cell disease is possible in Cameroon. To the best of our knowledge, the present study is the first report of PND experience in the Central African region.
Background (max 200 words): The Republic of Cameroon is a sub-Saharan African country with a population of about 20 million. The health-care system of the country is organized into the public, orthodox private and traditional private sectors. There is no universal medical insurance coverage in Cameroon. With a carrier frequency of 8 to 34%, the country has developed a national control program for sickle cell anaemia (SCA). Nevertheless, prenatal genetic diagnosis (PND) has not yet been incorporated in this strategy. Despite a low acceptance (36.1%) of the termination of an affected pregnancy (TAP) for SCA by Cameroonian physicians, up to 95% of Cameroonian parents with an SCA-affected child would request PND and 65% would opt for TAP. PND for SCA was initiated in Cameroon in August 2007.
Objectives (max 100 words): The main objective of the present study is to discuss the preliminary evaluation of the 36-month practice of prenatal genetic diagnosis of sickle cell anemia in Cameroon.
Methodology (max 400 words): The study included all patients consulted regarding PND of SCA from August 2007 to January 2011.  Fetal sampling was performed under ultrasound guidance by two obstetricians. Informed written consent was obtained from each patient. All the DNA samples of the parents and that of the fetus were extracted in Yaoundé, from peripheral blood and amniotic fluid, respectively, following instructions on the available commercial kits (Puregene blood kit®, Qiagen®, USA; and NucleoSpin® Blood QuickPure, Macherey-Nagel GmbH & Co ®, Germany). The molecular analyses for all the cases were done in the Service of Genetic Medicine of Geneva University Hospitals, Switzerland. Molecular analysis for the sickle cell mutation was carried out by PCR-restriction fragment length polymorphism (thermocycler from BIORAD®, USA; Dde I restriction enzyme from by GIBCO-BRL®, USA). In addition, any maternal contamination was also excluded. Maternal contamination was picked up on one occasion and the amniocentesis was repeated.
Results (max 400 words): A total of 42 patients presented for PND of SCA. Most patients were university graduates of Christian faith.  Amongst them, 93.9% had a family history of SCA, with either an SCA-affected child (59.5%; N = 25) or SCA-affected sibling (35.7%; N = 15). The possibility of having a child with SCA was not realized by 85.7% (N = 36) before marriage. Prior to the availability of PND in Cameroon, nine parents (21.4%) admitted to having voluntarily terminated at least one pregnancy for fear of having an SCA-affected child. The majority of patients (90.4%; N = 38) were counseled by the medical geneticist. Following counselling, two patients declined PND because of financial reasons; one for religious reasons and one had a spontaneous abortion prior to the scheduled date of amniocentesis. Thirty-eight patients underwent transabdominal amniocentesis, at an average gestational age of 16.3 weeks (range 13–23 weeks) with two procedure-related abortions. Late amniocentesis (above 21 weeks) was carried out on three patients (7.9 %). Three cases required repetition of amniocentesis; the reasons were maternal contamination (1/3) and failure of DNA extraction (2/3). Polymerase chain reaction-restriction fragment length polymorphism revealed ten fetuses affected with SCA (26.3%). Nine of these SCA-affected pregnancies (90%) were terminated.  The only patient who declined termination of an SCA-affected pregnancy stated ethical reasons; the pregnancy was 24 weeks at the time of result delivery, because of late referral and transportation time of the DNA samples to Geneva.
Conclusion (max 400 words): The practice of PND of SCA is possible in Cameroon. There is a need for open discussion of its ethical and legal challenges. The preliminary experience emphasizes the need for national and international collaborative efforts to overcome the lack of human, technical and financial resources.

Electronic Health Record as a Source of Information to Assess Quality of Healthcare for Hypertensives: Mexico

Author(s): Svetlana Doubova1, Ricardo Pérez-Cuevas2, Magdalena Suárez1,  Dennis Ross-Degnan3, Anita Wagner3
Affiliation(s): 1Epidemiology and Health Services Research Unit, Mexican Institute of Social Security, Mexico, 2Ministry of Health, Mexico, 3Harvard University, United States
1st country of focus: Mexico
Relevant to the conference theme: Health information and technologies
Summary (max 100 words): The objectives of this study were a) development of quality of care indicators (QCI) for hypertensives in Mexico; b) to determine the feasibility of constructing QCI using electronic health record data; and c) to evaluate the quality of care (QC) provided to hypertensives.   Methods: The study had a mixed method approach which included 48,048 hypertensives.  Results: 14 QCI emerged by using the available EHR (Electronic Health Record) data. The study demonstrated that it is feasible to evaluate QC for hypertensives using the EHR data yet substandard quality in processes and clinical outcomes was observed.
Background (max 200 words): In low and middle-income countries (LMIC) the growing prevalence of hypertension and premature mortality from its complications is a public health problem. Blood pressure control in hypertensives reduces mortality and morbidity, however, more than half of them are untreated and only 23% -46% achieved recommended blood pressure levels. It has been reported that the higher QC for patients with hypertension is associated with better control of their blood pressure, highlighting the importance of measuring QC, in order to identify failures and implement improvement strategies. One of the tools to improve QC is the use of EHR; which is 'a longitudinal collection of information about patient’s general characteristics, medical history, healthcare received and health outcomes. The use of EHR can improve the QC through its continuous monitoring, increased adherence to clinical guidelines, decreased medication errors, and other strategies.  In order to facilitate and improve the QC, the EHR is widely deployed in developed countries but in LMIC the experiences are limited. Only a few LMIC countries like Argentina, Costa Rica and Peru introduced EHR for research in small-scale settings. Mexico introduced the EHR at institutional level in the Mexican Institute of Social Security (IMSS). The IMSS is responsible for the care of 47% of the Mexican population and has a network of 1,516 family medicine clinics (FMC). In the IMSS, hypertension and other cardiovascular diseases are among top causes of ambulatory and hospital care. Nevertheless little is know about the QC that patients with hypertension receive. Currently the EHR information is not available on a routine basis to measure QC for this population.
Objectives (max 100 words): The objectives of this study were a) development of QCI in the Mexican Institute of Social Security (IMSS) health system; b) to determine the feasibility of constructing QCI using the IMSS EHR data; and c) to evaluate the QC provided to IMSS patients with hypertension.
Methodology (max 400 words): Methods: The study had a mixed method approach consisting of: 1) Development of QCI for hypertensive patients using the RAND-UCLA method; 2) Extraction of routine EHR data and construction of predefined QCI; 3) Evaluation of quality of care for hypertensive patients who received healthcare at Family medicine clinics in 2009. Setting: 4 FMCs in Mexico City. Study Population: 48,048 patients with hypertension who received care in 2009.
Results (max 400 words): Results: We developed 20 QCI, of which 14 were possible to construct using available EHR data. QCI comprised both process of care and health outcomes. Among 48,048 patients with hypertension, 64% were women, 66.7% were ≥60 years of age; 70% were overweight or obese (BMI ≥25.0 kg/m2); 30.9% had diabetes and 7.4% arteriosclerotic diseases. 51% of patients were prescribed one antihypertensive drug, 19.2% two, 4.3% received 3 or more antihypertensive drugs and 25.5% had no antihypertensive drugs prescriptions. The most frequently prescribed drugs were inhibitors of angiotensin converting enzyme (50%). The indicators of QC showed that during 2009, only in 15% of patients with newly diagnosed hypertension (in 2009) the diagnosis was based on the records of at least three blood pressure (BP) measurements with systolic ≥ 140 mmHg or diastolic ≥ 90 mmHg. Just 10% of them were ordered urinalysis, serum creatinine, fasting plasma glucose and total cholesterol. Regarding timely detection of complications: 39.8% of subsequent hypertensive patients without diabetes had fasting plasma glucose measurement at least once in the last 12 months; 37.8% of them had serum creatinine test; 43.2 had total cholesterol measurement and 10.0% were referred to the ophthalmologist. Regarding non-pharmacological and pharmacological treatment only 3.3% of obese hypertensive patients received nutritional counseling; 53% of patients with total cholesterol >= 240mg/dl or total cholesterol 200-239mg/dl and one or more of the following CV risk factors: smoking, diabetes or established atherosclerotic diseases were prescribed statins. 61.3% of patients with systolic BP ≥ 140 mmHg or diastolic ≥ 90 mmHg in the last 3 consultations and with 3 antihypertensive drugs were referred to the second level of care. Regarding health outcomes: 62.8% of hypertensive patients without diagnosis of diabetes and / or chronic kidney disease had blood pressure below 140/90 mmHg in the last 3 measurements; nevertheless 7.4% of  hypertensive patients with type 2 diabetes or chronic kidney disease had blood pressure below 130/80 mmHg in the last 3 measurements. Furthermore, 1.5% of patients had a cardiovascular event (myocardial infarction, cerebral vascular event, arterial thrombosis) in the last year.
Conclusion (max 400 words): The study demonstrated that it is feasible to evaluate QC for hypertensive patients using the IMSS EMR data. The results highlight the need to improve processes and clinical outcomes of guideline-based care for hypertensive patients in Mexico.

Type 2 Diabetes and Migrants: A Twelve Country Study

Author(s): Manuel Carballo1, Klea Faniko2, Alexandre Lefebvre1
Affilation(s): 1International Centre for Migration, Health and Development, Geneva, Switzerland, 2University of Geneva, Switzerland,
1st country of focus: Greece
Additional countries of focus: Austria, Canada, Germany, Ireland, Italy, Netherlands, Norway, Portugal, Spain, Switzerland, UK
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): This twelve country study (Austria, Canada, Greece, Germany, Ireland, Italy, Netherlands, Norway, Portugal, Spain, Switzerland, UK) addressed the prevalence of type 2 diabetes (T2DM) in migrant and non-migrant populations and responses to its diagnosis and management.  Respondents were recruited from health care facilities and they were interviewed using a standardized questionnaire in their language of choice.  Statistically significant differences emerged between migrants and non-migrants with respect to a number of health care indicators, and the study highlights the importance of reaching out to migrants with T2DM diagnostic and therapeutic services designed around their particular needs and sociocultural situation.
Background (max 200 words): Over the last two decades the number of people with diabetes mellitus (T2DM) has increased by almost 50 percent. While better diagnosis and reporting may in part account for this increase, there is growing evidence that the problem is in fact becoming more common in developing as well as developed countries, and that migrants and ethnic groups tend to have a higher risk of developing T2DM than other groups do.  Chronic psychological stress, poor nutritional acculturation, radical changes in lifestyle and difficulties with health care in general may be important factors in the development of T2DM in migrants and ethnic minorities. There is also evidence that migrants and ethnic minorities are not always able to benefit from diabetes-related programs as they are currently structured.  There is a growing understanding that the complex relationship of T2DM and migration must be better characterized and that more should be done to ensure that migrants and ethnic minorities are reached with timely prevention, diagnosis and care programs that take into account their risk factors and special needs.
Objectives (max 100 words): The overall aim of the project was to provide a body of socio-epidemiological data that could form the basis for national policies and programs, including training of healthcare personnel and development of guidelines that can be used in the day-to-day prevention, diagnosis, care and treatment of T2DM in migrants and ethnic minorities.  The specific objectives of the project were to: • define what is currently known about the link between migration and T2DM and its treatment/management in migrants;• determine the incidence/prevalence of T2DM among people meeting the study definition of “migrant”, and identify contributing factors;• describe how people meeting the study definition of “migrant” perceive T2DM and its care and treatment/management;• assess how healthcare personnel working with people who meet the study’s definition of “migrant” and are diagnosed with T2DM perceive their interaction with them;• assess how a control group of non-migrants with T2DM perceive the disease and its care and self-management;• develop a program to sensitize stakeholders, including migrants, their families, health care personnel and others, on the needs of migrants with respect to T2DM;• develop guidelines on the prevention, diagnosis, care and treatment of diabetes in migrants and ethnic minorities;• develop public information materials for migrants (and ethnic minorities) on T2DM prevention, diagnosis, care and treatment;• develop training materials and training programs for healthcare personnel on the theme of multi-cultural health care with special reference to diabetes;• evaluate the impact of these interventions by measuring changes of attitudes and knowledge among healthcare personnel and migrants (and ethnic minorities).
Methodology (max 400 words): The study focused on four groups of interest: migrants and non-migrants diagnosed with T2DM; healthcare staff working with migrants and others with T2DM.  Respondents were recruited from pre-selected public health care facilities in locations with a known high presence of migrants.  Respondents were recruited with the agreement of healthcare authorities and patients.  Contact with respondents was made by letter from the PIs in the countries concerned.  Healthcare personnel working with migrants with T2DM were also contacted directly by the PIs.  All migrants and non-migrants were aged between 35-59 years, and PIs were also asked to ideally involve healthcare providers within the same age-range as the patient/respondent group in order to minimize possible “time-cultural” differences.  Participating centers were asked to select and interview the following; between 50 and 100 migrants with T2DM; between 50 and 100 non-migrants with T2DM; at least 20 healthcare staff providing diabetes care to migrants and others.  Information about the study and its aim was disseminated through local healthcare facilities in each city and through associations, clubs and other facilities known to be frequented by migrants and non-migrants.  Potential participants in the study were given details on the purpose of the study, namely to improve the quality of care available to migrants and others with respect to diabetes, and were given an opportunity to ask questions about the study.  They were assured of confidentiality.  No incentives were offered, but in cases where the participant requested assistance with counseling or referral, this was provided.  Face-to-face interviews were conducted using structured questionnaires specially developed for the purpose of the study by interviewers who were capable of speaking the language of the respondents. If respondents chose not to participate in the project, this was recorded as a refusal.  If respondents started and then decided to discontinue the interview, it was recorded as a discontinued interview and the reason was recorded.  The interviews lasted approximately 40 minutes.  Focus groups were also organized to generate information from health care personnel using guidelines developed specially for the purpose of this study.  Data entry was done locally on an on-going basis using data entry sheets provided by ICMHD and sent to ICMHD and analyzed centrally.
Results (max 400 words): Statistically significant differences emerged between migrants and non-migrants in a number of areas, such as knowledge about T2DM, factors influencing its occurrence, its short and long-term implications, the ways in which it can and should be managed, and where help can be had if and when complications arise.  Attitudes to T2DM also differed; migrants were far more inclined to take a more fatalistic view of the disease than non-migrants were.  There were also significant differences with respect to the circumstances in which T2DM was diagnosed; data from all the countries suggested that migrants tend to be diagnosed with T2DM as a result of other health problems/complaints and not as a result of regular checkups; almost 60% of migrants with T2DM had been diagnosed during medical examinations for other problems including occupational injuries.  On the whole, migrants diagnosed with T2DM were much more likely to say that the diagnosis had been poorly explained to them, or that they had not understood what had been said. There was also a fairly widespread feeling that the people treating them were not interested in them as migrants or in their needs, even though the diagnostic setting was typically described as friendly. Migrants frequently expressed concern at not feeling sufficiently “in control” of their lives to manage their diabetes, and they had much more difficulty keeping appointments with healthcare providers.  They were also more likely to use emergency call numbers (hotlines) for diabetes related problems than non-migrants.  One of the background characteristics we believe may be important in the development of T2DM is the relatively large proportion of migrants who had been separated from their significant others by migration and who said they were chronically stressed.  There was a clear tendency for migrants to also have less economic/occupational security than their host population equivalents; contractual employment was less common among migrants and was also seen by them as a source of stress. There was also a tendency for migrants to work longer hours than non-migrants and have little time for personal activities including cooking, a fact that they said contributed to their use of pre-prepared foods. In accordance with what has been observed elsewhere, migrants were also more likely to be living in overcrowded dwellings and sharing accommodation with a number of people to whom they were not related.
Conclusion (max 400 words): The prevalence of T2DM is significantly higher among migrants than non-migrants in Europe and Canada. A number of factors may be linked to this, including chronic stress, rapid and often difficult changes in lifestyle, high dependence on ready-made foods and fast foods outlets, poor awareness of the factors contributing to T2DM and the importance of T2DM as a disease. It is also clear from the study that the diagnosis of T2DM in migrants often occurs incidentally to other complaints and not as part of any targeted regular checkups. Migrants also appear to have more difficulty coping with T2DM than non-migrants and in many cases do not have the level of personal control needed to make self-treatment easy or successful. On the whole communication between healthcare providers and migrants with respect to explaining the nature of the disease, the contributing factors and ways of dealing with it is also lacking, and many migrants tend to interpret this as a lack of interest on the part of healthcare providers in them as migrants and, in particular, as people with different medical and socio-cultural histories. In view of the growing problem of T2DM and the growing magnitude of migration it is clear that much more will have to be done to tailor national diabetes strategies in ways that address the specific needs of this new population. There is a need for more and better outreach to migrants, and there are grounds for promoting regular screening for T2DM in migrants.  Certainly more needs to be done to convey to migrants what the risks of developing T2DM are and what the main factors contributing to those risks are.  It is also clear that providing psychosocial support to migrants could well help them to manage their diabetes better and be less reliant on health care providers and emergency care in particular.  Although this type of intervention might at first seem costly, it is probably one of the more cost-effective investments that can be made once migrants have been diagnosed with T2DM.