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Mira Shiva

MiraShiva200x150Dr Mira Shiva

Chairperson, Health Action International Asia -Pacific Founder, People's Health Movement

Born to a Gandhian mother and a forest conservator father, a qualified doctor herself, Dr Mira Shiva chose to live the life of an activist. Single by choice in a man's world, Shiva has not just left her mark but has successfully made a difference to society…

Her journey started from Ludhiana in 1968, when she was doing her MD from Christian Medical College. When Dr Mira Shiva was a student, she observed women were dying during child birth and the college was making efforts to prepare doctors for situations like these. It was in this college that Shiva met Dr Betty Cowan, a Professor of Medicine and Community Health who later became her inspiration. "In her I found a person motivated by community health concerns," says Shiva.

Turning point

Shiva happened to be in Bihar in 1979-80 when there was an outburst of tuberculosis in the area. "There was a spread of tuberculosis and there were no anti TB drugs available in that area. All irrational hazardous combinations were flooding the market. That was the time that I felt the pain in my heart and thought that I must take this up with the chemical ministry," recalls Shiva. This marked the major turning point in her life.

Thereafter, Shiva has never looked back. She knew what she wanted to do next. Confident in her thoughts, she followed her mind. "I always wanted to become a doctor and practice medicine but I also wanted to serve human kind," she says.

Making a difference

Shiva has made many remarkable efforts in order to make this world a better place to live in. She has been associated with civil society bodies and has been part of many government committees representing the voice of masses.

Shiva was a member of the Drug Pricing Review Committee in 2001, as well as the Chemicals Ministry and the R& D Committee in the same year. Besides, she has played an important role as a member of various bodies like the Central Council for Health, National Population Commission, National Advisory Committee on Assisted Reproductive Technologies and National Human Rights Commission. She was also on the Task Force on Safety of Food and Medicine and was Chairperson of the Task Force on Consumer Education. Shiva is also associated with civil society bodies like Health Equity and Society, All India Drug Action Network and Health Action International Asia Pacific. She is a founder member of Peoples Health Movement and a steering committee member of Diverse Women for Diversity.

But is it easy for a woman activist to fight for rights of women and poor people amidst powerful men? "There are always men to de-legitimise my presence but I am always too firm to make my way and tell them my purpose to be there. The fact that I happened to be a woman is not so important to me," declares Shiva. She has rather learned from her experience to handle people and she feels it is important for every woman to do so too. "It is important to understand that you are saying what you are saying and being a woman does not mean that you are asking for a favour," she adds.

For namesake

The lady, who named herself after Mira Bai, says that she knew that she was born to become a rebel. "I named myself after Mira Bai because people tried to kill her in three different ways but failed. I draw my inspiration from there," she says. However, born to a family with liberal thoughts, Shiva gets her strength from her Gandhian mother, who was a writer and faced odds in her life as well, as well as her grandfather, who had set up a school for girls in rural areas. Her parents were very supportive of her decisions and gave her the freedom to choose. "I got it as a sanskar that I am no less than others and that there is no difference between a boy and a girl. If you underestimate me as a girl you are asking for trouble," she declares.

But women often face attacks on their identity from a patriarchal society. So did Shiva. "I have been repeatedly addressed as ‘Mrs Mira Shiva’ and by people who know my status but each time I used to make it a point to raise my voice and correct them …I will tell them I am not Mrs Mira Shiva but Dr Mira Shiva…It has something to do with my identity and it is important to me. People try to weaken you through such means. They would tell me that I am acting non-professional and speaking for a certain section which is not true," she says. Shiva points out that men occupying positions of power expect women to follow instructions and agree with them on whatever they say, so she was naturally not like by them. But she wonders, had she been born a man , then would the reaction from men be similar? The question remains unanswered …

Making heathcare affordable to poorest communities through acupuncture: India

Author(s) Walter Fischer1
Affiliation(s) 1Barefoot Acupuncturists, Barefoot Acupuncturists, Mumbai, India.
Country - ies of focus India
Relevant to the conference tracks Health Systems
Summary Barefoot Acupuncturists is a non-profit organisation registered in Belgium and founded by acupuncturist Walter Fischer in 2009. We run acupuncture clinics in slums of Mumbai and villages in Tamil Nadu (south of India), and also train local acupuncturists in order to encourage autonomy.Our services have been developed to give the poorest communities access to affordable and efficient healthcare, limited mainly to pathologies for which acupuncture has been recognised and proven (among others by the WHO) to be an effective treatment.
Our range of action covers chronic or acute pain, paralysis and stroke recovery, digestive disorders, fatigue, gynaecological issues and hypertension.
What challenges does your project address and why is it of importance? In India the healthcare sector, which is highly privatised, urged around 39 million people to fall into poverty in 2004-2005 because of out-of-pocket expenditures for their treatments.
India is the country with the largest number of poor people in the world and also has one of the most privatized healthcare systems.
It was estimated in 2010 that in India there was a shortfall of 100.000 doctors and 1000.000 nurses.High absenteeism and corruption amongst health workers discourage the poor to access public facilities. Surveys have pointed out that even when the poor try to seek medical assistance in the public sector, richer people have a greater share of public services.The challenge we are trying to address with Barefoot Acupuncturists is the great disparity between rich and poor, between public and private health systems, in which the poorest:
- choose to be treated in private sector at a high cost that puts them at even higher risk in terms of financial insecurity and social instability.
- often choose low quality publics services with the risk of not being taken care of properly and with the threat of developing more chronic diseases, which in the long term might negatively impact their future.

In both cases, the poor become poorer.

How have you addressed these challenges? Do you see a solution? We have been trying to address that great disparity between rich and poor in healthcare by providing efficient and affordable health services to the poorest through low-cost acupuncture clinics and offering acupuncture training to local communities.
Acupuncture is a unique tool not only for social health practitioners as it is cheap, effective and easy to teach. It treats pain and illness without harmful side effects. A healthcare system provided by local «barefoot doctors» who offer first-line services is a simple solution to ensure much-needed healthcare in slums or rural areas where there is little or sometimes no access to medical facilities.Why is acupuncture a unique tool against poverty:
Acupuncture from an economic perspective:
• Allows treatment at a low cost (acupuncture equipment is cheap).
• Is highly adaptable to different environments due to its simplicity and portability.
• Provides an alternative to expensive and sophisticated treatments.
Acupuncture from a healthcare perspective:
• Offers a proven and effective solution to health related issues.
• Can offer help in cases that have not been successful with conventional medicine.
• Can reduce the excessive use of chemical drugs and their potential side effects.85% of our patients consult for pain related to musculoskeletal disorders.
Coolies, farmers, workers, housewives, drivers, and maids are the majority of people at the lowest economic level who earn their living through physical works. Those are our patients.
Because their body is overused, often misused, and because of poor living conditions, this group will suffer more than others from physical pain. At the same time, they cannot afford to remain inactive without wages. Acupuncture (well known for and particularly effective against pain) allows them to recover faster and better.
The well-known efficiency of acupuncture against pain has not only been an observation through our practice in India, but globally in our acupuncture clinics around the world. In 2002 The World Health Organisation (WHO) issued a detailed report about acupuncture and a list of diseases for which through controlled clinical trails acupuncture has been proven to be an effective treatment.

- In 5 years, we have treated more than 3.500 patients, both in slums and villages.
- Today we offer 10.000 treatments every year.
- We are employing a team of 20 local people, including 7 acupuncturists.
- We are preparing to organise acupuncture trainings at a larger scale.

How do you know whether you have made a difference? We are presently making a difference at a very local level, in the slums and the villages where our clinics operate. Our clinics are busy due to our reputation spreading in the community by patients who have been encouraged to consult us by relatives or neighbours who were treated by our barefoot acupuncturists and found relief and solutions to their health problems.
A medical survey and various testimonies have shown and explained the impact and the level of satisfaction among slums dwellers and villagers.
Although our impact is clear upon surrounding poor communities, it is true that we lack scientific data to support our field experience and to quantify that impact.
We plan to hire specialised external skills to enable us to build our practises and communication.In order to expend our impact to other areas, others states in India and later in different countries, Barefoot Acupuncturists is developing an acupuncture training program. This program is aimed at the staff of local NGO’s that will fully manage their own acupuncture clinics, based on their own network and financial resources. This will allow an exponential growth of low-cost clinics, independently of Barefoot Acupuncturists’ human and financial resources. By bringing all the knowledge and tools into the hands of local communities, we hope to create more sustainable growth and functioning.
Have you or the project mobilized others and if so, who, why and how? - Founders: private founders in Europe and India have supported us financially and made it possible for our project to develop during these 6 years.
- Around 30 experienced acupuncturists and medical doctors from all over the world have joined us to work and teach in our Indian clinics.
- In 2012 we signed a collaboration with the "World Federation of Chinese Medicine Societies", an important group of Chinese doctors and professors in Beijing (China) to work on the elaboration of an acupuncture training manual.
- The Foundation Frédéric et Jean Maurice in Switzerland has offered us financial and technical support.
- The association "Humanitarian Acupuncture Project" was created in 2012 in the United-States by American acupuncturists to support our work in India with funding and volunteer acupuncturists.
- Two Indian organisations, UnLtd India and Toolbox, have been advising and coaching us for the year to help us strategise our goals and grow more efficiently.
- Professionals from various fields share their skills continuously with us: graphic designers, photographers, web designers, professional development coaches, accountants, lawyers, film makers…
When your donor funding runs out how will your idea continue to live? Today Barefoot Acupuncturists fully manages and finances all its activities. If funds run out, clinics close and all our patients lose the benefit of our services. This is the main reason (added to the need of a better cost-efficiency ratio) why in the following two years we are preparing to become an organisation offering acupuncture training to local NGO’s and communities, making possible not only an exponential growth but also sustainable structures that will function independently from Barefoot Acupuncturists resources.

Dental Services in the CESCO of the HUG: An Audit

Author(s): M. Schimmel*1, P. Schoeni2, G. B. Zulian2, F. Müller1
Affiliation(s): 1Division of Gerodontology and Removable Prosthodontics, Medical Faculty, University of Geneva, 2Department for Rehabilitation and Geriatrics, University Hospitals of Geneva, Switzerland
Keywords: Treatment demand; utilisation; dental care; palliative care; long-term care
Background:

Dental care plays an important role in the multidisciplinary approach which is used in palliative and long-term care to address the complex needs of terminally ill patients. The aim of the present study was to assess the utilisation of dental services in a University Hospital Palliative and Long-term Care Unit.

Summary/Objectives:

Over an observation period of 13 months, during 2/10 per week structured questionnaires were filled out after each dental appointment. The survey covered three main topics: the initiation and incentive of the dental consultation, particular difficulties due to the patient’s health or the hospital’s organisation as well as the accomplished treatment. The aim of the present study was to assess the utilisation of dental services in a University Hospital Palliative and Long-term Care Unit.

Results:

275 questionnaires from a total of 102 patients were available for analysis. The patients’ median age was 83 years (SD 10.3, range 49-101 yrs), 63 were female, 39 male. The majority of first appointments was initiated by a physician (n=49 of 102), mainly because of pain (n=62 of 275). 10.5% of the appointments were cancelled on the same day. Only one fifth of the patients were able to reach the practice on foot. Six used a walking stick and 54 relied on a wheelchair. Eighteen patients needed to be seen in their bed. The most frequently performed procedures were extractions and removal of denture sore spots (n=67 of 275) followed by the manufacturing of new dentures (n=38 of 275). In over 17% of the appointments no particular treatment was performed.

Lessons learned:

The utilisation of dental services in terminally ill and severely compromised elderly patients shown, justifies a dental service in a palliative care or geriatric hospital setting. The particular dental work profile requires a practitioner with empathy and professional experience.

Cross-o-Pathy: A Concern about Public Health and Responsibilities of Universities

Author(s): M. Dutta1
Affiliation(s): 1Health, Gram Shastya Udyog, West Bengal, India
Keywords: Cross-o-pathy, alternative system of medicine, rural health, India
Background:

Health service in rural India mainly depends on doctors of alternative system of medicines, e.g. homeopathy, ayurveda (traditional medicine of India), Unani, etc. Medicines from alternative system of medicines are not so efficacious in tackling emergency and in acute conditions. Adding to it, rural Indian people used to ask for doctor’s advice only when the disease becomes unbearable and complicated. That’s why they ask for immediate relief also where these medicines of alternative systems fail to meet the demand. So it is very common practice prescribing modern medicine by doctors of alternative system of medicine without having any formal training in the same. This can be termed as cross-o-pathy.

Summary/Objectives: Keeping this in mind, the study has been conducted to assess the frequency of cross-o-pathy in rural India. It has been studied in Narayangarh block of Midnapur District, West Bengal, India among 71 rural doctors of different alternative systems of medicines as per pro-forma of survey with prior informed consent of those. Practitioners having no university recognized degree have been excluded from the study. (1) Do they practice purely their pathy in which they trained or they prescribe medicine of modern or any other system of medicine? (2) Which groups of modern medicines they used to prescribe frequently? (3) Which groups of medicines of their own pathy, they used to prescribe frequently? (4) What are the diseases, they used to treat with modern medicine? (5) What are the diseases, they used to treat with the medicines of their own pathy? (6) Do they have any exposure or formal training in modern medicine? (7) What do they think-Is it ethical to prescribe medicines of pathy, other than they trained?
Results:

36 homeopathic practitioners, 25 practitioners of ayurveda used to do practice modern medicines especially in acute conditions.8 homeopathic practitioners and 2 ayurvedic practitioners practice purely the pathy, they trained. All the doctors of alternative systems of medicine have some official exposure of different procedures in different modern hospitals though they are not trained in modern medicines. They gain knowledge in modern medicine through self reading, taking tuition/ doing work as assistant of modern doctors, unofficial training on modern medicine in different hospitals, mainly private for the sake of survival as practitioner in rural India. The cross-o-pathy practitioners used to treat infectious diseases, acute pain, etc with the help of modern medicine (mainly antibiotics, steroid.) and psycho-somatic disorders, renal stones, peptic ulcer, various liver disorders etc with the help of alternative system of medicine. They also used to prescribe nutrient supplements, immuno-modulatory food supplement of alternative systems of medicine. It has been also observed that cross-o pathy among different alternative systems of medicine is also present, though not frequent. They who practice purely of their own pathy prescribe their own system of medicine in various disorders, in which patient may get relief; otherwise they refer the patients. It has also been observed that the pure practitioners are mainly based on little urbanized rural area. All the cross-o-pathy practitioners agreed that it is unethical to prescribe medicines, other than they trained. But, it is very difficult to survive as practitioners in rural India and the clinical situation demand immediate intervention as well as relief to the patients.

Lessons learned:

So the degree awarding universities, different regulatory bodies, policy makers should realize the ground reality and take proper measure like proper training in modern medicine to the doctors of alternative system of medicine or supply of sufficient modern doctors in rural India for the benefit of rural downtrodden Indians.

Effect of Nurses’ Continuing Education and Institutionalization on the Cancer Pain Assessment 1

Author(s): H. J. i. h. Jen1
Affiliation(s): 1Nursing, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
Keywords: Cancer pain, pain assessment, continuing education, institutionalization
Background:

Pain is experienced in 30-50% of cancer patients during active antineoplastic therapy and in 60-90% of patients with advanced cancer. One of the root causes for inadequate medication is inadequate pain assessment. Therefore, a hospital-based quasi-experimental study was implemented to evaluate the effect of a continuing education and institutionalization programme (CEI) on nurses’ cancer pain assessment. There were 57 frequency-matched patient-nurse dyads were interviewed by the structured questionnaire at three different stages (pre-test, post-continuing education and post-institutionalization). After these 171 patients were discharged, their chart were reviewed and abstracted. Chi-square test and ANOVA were used in the statistical analysis.

Summary/Objectives:

In conclusion, CE and institutionalization of cancer pain assessment were effective in cancer pain management in two different fields, one was the improvement of patient’ pain severity and satisfaction and the other was the improvement of nurse’s practices of cancer pain assessment.

Results:

The results showed that CE only made statistically significant improvement on patients’ pain impact of relationship, pain impact of sleep, satisfaction, and hesitancy to report pain. Additionally, institutionalization made significant improvement on patient’s now pain and average pain severity, nurses’ accurate assessment of patient’s pain ratings of mild pain and expected pain, and documentation of pain assessment.

Lessons learned:

Quality comes from improving the process, not evaluating the output after fact. The suggestion was that the head nurse of the ward audited actively on unit and rewards for chart documentation. The management of good quality required the good administrator. To whom persisted endless of quality improvement, they can study the further analysis and comparison within five years after institutionalization.

An Assessment of Premenstrual Syndrome and Premenstrual Dysphoric Disorder in Young Adults in Tehran University of Medical Sciences

Author(s): N. Raeesi*1, H. Gharaie2
Affiliation(s): 1Research Centre, Tehran University of Medical Sciences, Iran (Islamic Republic of), 2Women’s Affairs Office, Ministry of Health and Medical Education, Iran
Keywords: Premenstrual syndrome, premenstrual disphoric disorder, life style
Background:

Menstruation is an important biological phenomenon and studies concerning menstruation need to take into account life style and cultural and psychosocial factors that define the meaning, values and behaviour associated with this phenomenon.

Summary/Objectives:

The objective of the current study was to evaluate the prevalence of a potential premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) during one menstrual cycle, in a representative sample of young medical university students of Tehran, according the Pennsylvania University criteria. On the other hand, a questionnaire, available from the author, was used to explore socio-demographic data.72 students were interviewed that the mean age of them was 21.20 years.

Results:

72 students were interviewed that the mean age of them was 21.20 years, 34 met the criteria of a potential PMS (47.21%), 20 of them showed PMDD (27.77%) and 25% of them had no complications in this area. During the premenstrual phase the following symptoms were found among the proportion with PMS and PMDD (74.98%): marked depressive mood(81.48%); difficulty of concentration (33.33%); being nervous and anxious(24.07%); irritability and angriness (75.92%) marked increase in appetite (48.14%); moodiness, sadness (48.14%); hypersomnia or insomnia 51.85%; sense of being overwhelmed (25.92%); lethargy, excessive fatigability (53.70%) and physical symptoms including breast tenderness, swelling, headache, joint or muscular pain, and a sensation of bloating and weight gain (72.22%). On the other hand, 53.70% of the sample had a disturbance in their socio-professional lives as a consequence to the psychological disturbances. Just 18.51% of these women consulted a physician, and 24.07% used drugs (mostly herbal ones). Exactly half of them experienced painful periods and 37.03% reported irregular ones. Some of these students expressed a lot of stress and tension in their study and relationships, 59.25 %. According to the questioner 40.74 %had wrong food habits. Unfortunately 83.33% of them didn’t exercise enough.

Lessons learned:

These data confirms that these disorders are common and have a bad impact on mental health and on quality of life of the women, when the mental health and quality of life at the same time affect the prevalence of these disorders.

Eco-Pharmacovigilance: A New Voncept of Pharmacovigilance in Environment

Author(s): S. Z. Rahman*1, R. A. Khan2, V. Gupta2, M. Uddin2
Affiliation(s):

1Pharmacology, Jawaharlal Nehru Medical College, AMU, 2Pharmacology, Jawaharlal Nehru Medical College, Aligarh, India

Keywords: Environment science, pharmacology, pharmacovigilance, pharmaco-environmentology
Background:

With growing technological advances, newer and more effective drugs are being manufactured are used on ever-growing scale for people with medical conditions. Pharmacovigilance activities are done to monitor, detection, assessment, understanding and prevention of any obnoxious adverse reactions to drugs at therapeutic concentration on animal and human beings. With growing research in the field of ecology and environment, many of the adverse effects of these drugs on the environment have come to light.

Summary/Objectives:

There is a growing focus among scientists and environmentalists about the impact of drugs on environment and surroundings. The existing term ‘Eco-pharmacology’ is too broad and not even defined in a clear manner. The first study that detected drugs in sewage took place in 1976 at the Big Blue River sewage treatment plant in Kansas City. In the meantime, a number of findings related to rising levels of some drugs and their adverse effects on the flora and fauna has necessitated some action by regulatory agencies like FDA and European Union. Still, there is a lack if substantial protocol for a prospective monitoring of drug concentration in the environment and the evident adverse effects.

Results:

A number of studies measuring the levels in surface water, groundwater and drinking water drugs given therapeutically to humans and animals including antibiotics, hormones, pain killers, tranquilizers, beta blockers and anticancers were found. Development of antibiotic resistance in pathogens in the environment owing to their exposure is the major concern. The term ‘Pharmaco-environmentology’ seeks to deal with the environmental impact of drugs given to humans and animals at therapeutic doses. Some concerns that need to be taken up under Pharmaco-environmentology are that of drugs and their exact concentration in different components of the environment including measures such as Eco-friendly techniques like bioremediation. Thus the objective of this paper is to analyse the subject and its incorporation with national pharmacovigilance programme, national and international regulations, definition and the use of various terms in this wide field of Pharmacovigilance.

Lessons learned:

Concept of Eco-pharmacovigilance

Measuring Violence and its Health Impact in an Urban Setting: Results of an MSF Survey in Cité Soleil, Port-au-Prince, Haïti, 2007

Author(s): M. Philips1, F. Ponsar*1, S. Mancini2, M. Van Herp3, C. Bachy1, L. Filippi4
Affiliation(s): 1Analysis and Advocacy Unit, Médecins Sans Frontières, BRUSSELS, Belgium, 2Analysis and Advocacy Unit, Médecins Sans Frontières, Rome, Italy, 3medical department, Médecins Sans Frontières, BRUSSELS, Belgium, 4Operations department, Médecins Sans Frontières, Rome, Italy
Keywords: Urban health, violence, mortality
Background:

Port–au-Prince has been shaken by violence for several years. Cité Soleil, a shanty town of 200.000 inhabitants, known to be the base of the “Chimères” -militias -has been the scene of violent fightings since the departure of Jean Bertrand Aristide in 2004. Civil population has been on the frontline of fightings between armed actors, including armed groups and the United Nations stabilisation mission for Haïti (Minustah). MSF health activities in Cité Soleil started in August 2005 at a time when fighting between armed actors were intense. In Cité Soleil, Choscal hospital was supported with a focus on emergency surgical response for victims of violence. A broader support to the hospital and to the Chapi health centre for primary healthcare was then organised. After 2 years of activities in the area, stabilisation of security situation made it possible for MSF teams to collect population data on violence and health.

Methods:

A simple random sampling survey was carried out from 31st July to 7 August 2007 to measure mortality, violence and impact of violence on health among Cité Soleil population. Sample size was determined on the basis of a mortality estimate at 2% per year. With a margin of error at +-0,4% and the average number of people per household estimated at 5, 945 households were needed. Sample distribution between the sub-sections of Cite Soleil was proportional to the number of buildings in each of these sub- sections. Houses visited were randomly selected on satellite map. The recall period considered for violence and mortality covered the period from the 1st of January 2006 till the date of survey.

Results/Conclusions:

945 households (HH) were interviewed (total persons 4763). Overall crude mortality rate was 0.4 deaths/10.000/day IC [0.4-0.5] and 0.5 for children under 5- IC [0.3-0.7]. (Sphere emergency thresholds for Latin America : 0.3/10.000/day and 0.4/10.000/day for children under 5). Violence was the first reported cause of death, accounting for 29.2% -IC [21.6-37.8]- of all deaths. Majority of violent deaths were linked to bullet shootings. Homicides rates were at 457/100.000/year for the studied period- IC [417-500]. Most of the victims of violence were men, specifically among the group aged 15 to 39 years old. For this specific group, homicide rates reached 1109/100.000/year- IC [1045-1175]. 52.4% -IC[49.2-55.6] of households reported that violence affected their belongings. Main forms of violence targeting belongings were bullet shootings on the house and theft. 22.9% of HH - IC [20.3-25.6] reported at least one individual victim of violence in their family. Main forms of violence reported against individuals were beatings, threats and bullet shootings. 81.6% IC [76.3-86.1] of victims declared having suffered from direct health consequences linked to the violent event. The main consequences reported were body pain, wounds and psychological trauma. 72,8% IC [ 66,9-78,2] of victims of violence searched for medical help after a violent event. More than a third used MSf supported facilities in Cité Soleil, mainly victims of bullet shootings needing emergency intervention. 74.1% IC [68.2-79.3] of victims also declared that, at the time of the survey, they were still physically or mentally affected by the violent event experienced.
Population data gathered about violence in Cité Soleil revealed a heavy impact of violence on mortality and population health status. Violence directly caused the death of a minimum of 1000 people in Cité Soleil during the period studied. Violence had direct consequences and also longer term impact on victims’ health. The disastrous impact of “violence ghetto” on physical and mental health conditions of general population, during and after peaks of violence clearly points out the necessity of an emergency response in these types of urban violent contexts.

Responding to Community depression in Africa by Utilizing Trained Local People to Provide Treatment Using Interpersonal Psychotherapy for Groups (IPT-G)

Author(s): L. Ndogoni*1, A. L. Schmidt-Fellner2, S. Germann2
Affiliation(s): 1HIV/AIDS Team, World Vision International, Nairobi, Kenya, 2Global Health Team and Global HIV Hope Initiative, World Vision International, Geneva, Switzerland
Keywords: Psychosocial, mental health, depression, community response, Africa, interperson therapy groups
Background:

Objective: To demonstrate the efficacy of community trained individuals to provide group IPT-G treatment to alleviate depression and dysfunction in resource scarce settings. Background: IPT-G is a known treatment for depression. However, it was only recently adopted and introduced to Africa by World Vision and University based partners through a randomized clinical trial in Uganda, in 2003. An assessment using culturally adopted tools showed depression rates of 21% and 19% in Zambia. Community facilitators are given 2 weeks training on IPT-G to provide treatment to individuals diagnosed with depression in their communities. In the communities surveyed, there was clear concept and signs and symptoms of depression, for example, “kuhinyiririka meciria” (squeezed brain) in Kenya and “kukwinyirira” (suppressed/pain in brain) in Zambia and as described in Diagnostic and Statistical manual of mental disorders (DSM-IV).

Results/Conclusions: About 60 facilitators have been trained in each country. Sixty facilitators are able to provide treatment to about 720 individuals within four months. Within 2 weeks after completing treatment participants were re-interviewed using pre-intervention assessment tools. Only three (3%) percent met the depression diagnostic criteria. The intervention improved the overall function of participants. Ninety five percent (95%) showed significant improvement in their daily function. In addition, strong bonds were established among group members; nearly all group members joined together to initiate sustainable economic activities. Conclusion: This work demonstrates the feasibility and efficacy of IPT-G to culturally identify and treat depression-like illness in resource scarce settings. Most important, the intervention can be delivered effectively by locally trained and supervised individuals. This provides opportunity to scale up evidence based mental health interventions to thousands of depressed people across Africa and elsewhere.

Reducing the Trauma of Hospitalization in Children in Macedonia and Serbia by Strengthening Health Worker Knowledge in Child-Centered and Developmentally Appropriate Care

Author(s): B. Schwethelm*1, P. Brylske2, E. Munn2, C. Capello1
Affiliation(s): 1Fondation Partnerships in Health, Partnerships in Health, Céligny, Switzerland, 2Child Life Services, Johns Hopkins Children’s Center, Baltimore, United States
Keywords:

Pediatric hospitals, child-centered care, child development and illness, pain management, hospital play, preparation, UN Convention of the Rights of the Child

Background:

Based on substantial evidence, developmentally appropriate preparation and care of children and adolescents can reduce the trauma and pain often associated with hospitalization, as well as the effectiveness of treatment and duration of hospitalization. Child- and family-centered care approaches have been implemented in more developed countries, but are absent in the Balkans region, with the exception of Croatia. Children are often treated without explanation and by using physical restraints; parents are not included in the treatment and care plans and have limited visiting hours; communication among hospital workers about treatment and child psychosocial factors is inadequate leading to duplication of invasive and traumatizing treatments; and techniques of psychological and pharmacological pain management in children are poorly understood. Partnerships in Health and staff of the Child Life Center, Johns Hopkins Children’s Center, US, have conducted a successful pilot training introducing child-centered care practices in Skopje, Macedonia. This led to the development of the current initiative to help hospitals in the region to upgrade their pediatric service in the context of globalization.

Methods: Based on a first pilot course, a five-day comprehensive curriculum was developed for pediatric and psychosocial hospital staff. Training components include the philosophy and evidence resulting from child and family-centered care; child development (including children’s understanding of illness at various levels of development; their likely responses to separation from families and friends and to hospitalization; their fears and potential coping mechanisms); the role and ways of preparation for hospitalization and interventions; the role of pain management on development and recovery and the introduction of effective coping strategies; the role of play in the hospital environment; hospital staff communication; the detection of child maltreatment; and toy and hospital environment safety issues. The curriculum includes detailed reference and audiovisual materials, case studies, trainer guidelines, and training power points, and training pre- and post-tests to allow the participants to share the information with staff at their institutions. The manual is also in process of being translated into Serbo-Croatian and Macedonian.
Results/Conclusions:

The first pilot course was implemented in 2008 with about 30 health professionals and has led to first changes in practices in the partner institution, the Kozle Institute. Lessons-learned from this pilot training were integrated into a formal curriculum that will be used for the first time with pediatric institutions in Serbia and Macedonia in February 2010. Both countries are indicating a strong interest among pediatric professionals and the Ministry of Health to improve health care experiences and medical interventions of children and their families in the hospital sector. This regional project contributes to closing some of the gap in the quality of care provided in pediatric hospitals in the Balkans region and Western European. By the time of the Geneva Forum, the aauthors will be able to share insights on the training, training pre-and post-test results, and plans of the training participants to implement child- and family-centered care practices in their pediatric institutions in Macedonia and Serbia. The initiative is in line with the UN Convention of the Rights of the Child and informed by the Child-friendly Hospital Initiative, Child Life, Family-Center Care, and similar approaches implemented by institutions in the industrialized world.