Adaptive adjustment to the needs of families caring for children and adolescents with physical disabilities in north-eastern Tanzania: a grounded-theory study.

BACKGROUND: Family interactions, which are always multi-faceted, are complicated further by family members with disabilities. In resource-poor settings, policies and programmes that address the needs of and challenges faced by families are often inaccessible or unavailable. Approximately 13% of the families in Tanzania have at least one member with a disability, yet family-centred research on caring for disabled children and adolescents is scarce in this context. OBJECTIVE: The aim is to explore the needs and challenges faced by families that care for children and adolescents with physical disabilities in the Kilimanjaro Region of north-eastern Tanzania. METHODS: This qualitative study had a constructivist grounded-theory design. In-depth interviews, using a semi-structured interview guide based on the social-capital framework, were conducted with 12 female participants aged between 24 and 80. A conceptual model of family needs, inspired by Maslow's hierarchy of needs, informed the analysis. RESULTS: Challenging needs were grouped into five categories, which were linked to Maslow's hierarchy of needs and related to the central concept of 'adaptive adjustment': (1) 'barely surviving'; (2) 'safety needs in jeopardy'; (3) 'sociocultural protection'; (4) 'self-esteem far beyond reach', and (5) 'dreaming of self-actualisation'. CONCLUSION: Families caring for children and adolescents with physical disabilities in north-eastern Tanzania have needs that extend beyond the available and accessible resources. Families can adjust and adapt by avoiding certain situations, accepting the reality of their circumstances and exploring alternative ways of coping. A sustainable support system, including social networks, is essential for meeting basic needs and ensuring safety.

Main findings: The challenges associated with caring for children and adolescents with disabilities are related to various environmental and social barriers, any of which can significantly impact the wellbeing of all family members.Added knowledge: In the context of a study conducted in north-eastern Tanzania, both nuclear and extended family networks were found to be valuable sources of support for these families.Global health impact for policy and action: Families must take considerable steps to strengthen their sociocultural support systems while, the support of the government and other stakeholders is crucial in addressing the challenges faced by families caring for children and adolescents with disabilities.

A systematic review on the direct approach to elicit the demand-side cost-effectiveness threshold: Implications for low- and middle-income countries.

Several literature review studies have been conducted on cost-effectiveness threshold values. However, only a few are systematic literature reviews, and most did not investigate the different methods, especially in-depth reviews of directly eliciting WTP per QALY. Our study aimed to 1) describe the different direct approach methods to elicit WTP/QALY; 2) investigate factors that contribute the most to the level of WTP/QALY value; and 3) investigate the relation between the value of WTP/QALY and GDP per capita and give some recommendations on feasible methods for eliciting WTP/QALY in low- and middle-income countries (LMICs). A systematic review concerning select studies estimating WTP/QALY from a direct approach was carried out in seven databases, with a cut off date of 03/2022. The conversion of monetary values into 2021 international dollars (i$) was performed via CPI and PPP indexes. The influential factors were evaluated with Bayesian model averaging. Criteria for recommendation for feasible methods in LMICs are made based on empirical evidence from the systematic review and given the resource limitation in LMICs. A total of 12,196 records were identified; 64 articles were included for full-text review. The WTP/QALY method and values varied widely across countries with a median WTP/QALY value of i$16,647.6 and WTP/QALY per GDP per capita of 0.53. A total of 11 factors were most influential, in which the discrete-choice experiment method had a posterior probability of 100%. Methods for deriving WTP/QALY vary largely across studies. Eleven influential factors contribute most to the level of values of WTP/QALY, in which the discrete-choice experiment method was the greatest affected. We also found that in most countries, values for WTP/QALY were below 1 x GDP per capita. Some important principles are addressed related to what LMICs may be concerned with when conducting studies to estimate WTP/QALY.

How does the distribution of work tasks among home care personnel relate to workload and health-related quality of life?

BACKGROUND: The work for Swedish home care workers is challenging with a variety of support and healthcare tasks for home care recipients. The aim of our study is to investigate how these tasks relate to workload and health-related quality of life among home care workers in Sweden. We also explore staff preferences concerning work distribution. METHODS: A cross-sectional study was conducted in 16 municipalities in Northern Sweden. Questionnaires with validated instruments to measure workload (QPSNordic) and health-related quality of life (EQ-5D), were responded by 1154 (~ 58%) of approximately 2000 invited home care workers. EQ-5D responses were translated to a Quality-adjusted life-year (QALY) score. For 15 different work task areas, personnel provided their present and preferred allocation. Absolute risk differences were calculated with propensity score weighting. RESULTS: Statistically significantly more or fewer problems differences were observed for: higher workloads were higher among those whose daily work included responding to personal alarms (8.4%), running errands outside the home (14%), rehabilitation (13%) and help with bathing (11%). Apart from rehabilitation, there were statistically significantly more (8-10%) problems with anxiety/depression for these tasks. QALY scores were lower among those whose daily work included food distribution (0.034) and higher for daily meal preparation (0.031), both explained by pain/discomfort dimension. Personnel preferred to, amongst other, spend less time responding to personal alarms, and more time providing social support. CONCLUSION: The redistribution of work tasks is likely to reduce workload and improve the health of personnel. Our study provides an understanding of how such redistribution could be undertaken.

Cost-effectiveness of Digital Tools for Behavior Change Interventions Among People With Chronic Diseases: Systematic Review.

BACKGROUND: Chronic diseases, including cardiovascular diseases, diabetes, chronic obstructive pulmonary disease, and cerebrovascular diseases, contribute to the most significant disease burden worldwide, negatively impacting patients and their family members. People with chronic diseases have common modifiable behavioral risk factors, including smoking, alcohol overconsumption, and unhealthy diets. Digital-based interventions for promoting and sustaining behavioral changes have flourished in recent years, although evidence of the cost-effectiveness of such interventions remains inconclusive. OBJECTIVE: In this study, we aimed to investigate the cost-effectiveness of digital health interventions for behavioral changes among people with chronic diseases. METHODS: This systematic review evaluated published studies focused on the economic evaluation of digital tools for behavioral change among adults with chronic diseases. We followed the Population, Intervention, Comparator, and Outcomes framework to retrieve relevant publications from 4 databases: PubMed, CINAHL, Scopus, and Web of Science. We used the Joanna Briggs Institute's criteria for economic evaluation and randomized controlled trials to assess the risk of bias in the studies. Two researchers independently screened, assessed the quality, and extracted data from the studies selected for the review. RESULTS: In total, 20 studies published between 2003 and 2021 fulfilled our inclusion criteria. All the studies were conducted in high-income countries. These studies used telephones, SMS text messaging, mobile health apps, and websites as digital tools for behavior change communication. Most digital tools for interventions focused on diet and nutrition (17/20, 85%) and physical activity (16/20, 80%), and a few focused on smoking and tobacco control (8/20, 40%), alcohol reduction (6/20, 30%), and reduction of salt intake (3/20, 15%). Most studies (17/20, 85%) used the health care payer perspective for economic analysis, and only 15% (3/20) used the societal perspective. Only 45% (9/20) of studies conducted a full economic evaluation. Most studies (7/20, 35%) based on full economic evaluation and 30% (6/20) of studies based on partial economic evaluation found digital health interventions to be cost-effective and cost-saving. Most studies had short follow-ups and failed to include proper indicators for economic evaluation, such as quality-adjusted life-years, disability-adjusted life-years, lack of discounting, and sensitivity analysis. CONCLUSIONS: Digital health interventions for behavioral change among people with chronic diseases are cost-effective in high-income settings and can therefore be scaled up. Similar evidence from low- and middle-income countries based on properly designed studies for cost-effectiveness evaluation is urgently required. A full economic evaluation is needed to provide robust evidence for the cost-effectiveness of digital health interventions and their potential for scaling up in a wider population. Future studies should follow the National Institute for Health and Clinical Excellence recommendations to take a societal perspective, apply discounting, address parameter uncertainty, and apply a lifelong time horizon.

Children and adolescents with physical disabilities: describing characteristics and disability-related needs in the Kilimanjaro region, north-eastern Tanzania - a cross-sectional survey.

OBJECTIVES: To describe the characteristics and disability-related needs of children and adolescents with physical disabilities in the Kilimanjaro region, North-Eastern Tanzania. DESIGN: A cross-sectional community survey was conducted from November 2020 to June 2021. Trained research assistants interviewed primary children's carers using a questionnaire based on the International Classification of Functioning, Disability and Health-Children and Youth Framework. Data were analysed using IBM SPSS Statistics V.27. The Pearson χ2 test was used to examine differences between age, gender and self-reported needs. The independent t-test assessed difference in needs according to age and gender. SETTING: Kilimanjaro region, Tanzania. PARTICIPANTS: Children and adolescents, aged 2-18 years, with physical disabilities (n=212). RESULTS: Almost 40% had severe speech (n=84) and joint mobility (n=79) impairments, and more than half (n=124) had severe or complete difficulties walking. In aspects of self-care (caring for body parts, toileting, dressing, eating and drinking), most had severe and complete difficulties. Almost 70% (n=135) of households were located near health facilities without rehabilitation services. About one-quarter (n=51) had never received rehabilitation services. More than 90% (n=196) needed assistive devices, and therapeutic exercises (n=193). Over three-quarters needed nutritional supplements (n=162). CONCLUSION: Children and adolescents with physical disabilities in North-Eastern Tanzania have impaired speech and joint mobility, and difficulties in communication, self-care and walking. Rehabilitation services essential for addressing these impairments and activity limitations are either scarce or inaccessible. Action is needed to facilitate urban and rural access to rehabilitation services in order to improve the well-being of children and adolescents with physical disabilities.

Estimating a social value set for EQ-5D-5L in Sweden.

BACKGROUND: The study aims to elicit a value set based on the EQ-VT for the EQ-5D-5L that can be used to support decision-making in Sweden. METHODS: Participants were recruited from the general population based on age, sex and urban/rural area quota sampling from five regions across Sweden. In total, 785 interviews were conducted from February 2020 to April 2021 using the EQVT 2.1 protocol, and both composite time trade-off (c-TTO) and discrete choice experiments (DCE) were used to elicit health preferences. A variety of models have been tested for the c-TTO data (generalized least square, Tobit, heteroskedastic models) and DCE data (conditional logit model), as well as the combined c-TTO and DCE data (hybrid modelling). Model selection was based on theoretical considerations, logical consistency of the parameter estimates, and significance of the parameters (p = 0.05). Model goodness-of-fit was assessed by AIC and BIC, and prediction accuracy was assessed in terms of mean absolute error. The predictions for the EQ-5D-5L health states between models were compared using scatterplots. RESULTS: The preferred model for generating the value set was the heteroskedastic model based on the c-TTO data, with the health utilities ranging from -0.31 for the worst (55,555) to 1 for the best (11111) EQ-5D-5L states. CONCLUSION: This is the first c-TTO-based social value set for the EQ-5D-5L in Sweden. It can be used to support the health utility estimation in economic evaluations for reimbursement decision making in Sweden.

Sequential Multiple Imputation for Real-World Health-Related Quality of Life Missing Data after Bariatric Surgery.

One of the main challenges for the successful implementation of health-related quality of life (HRQoL) assessments is missing data. The current study examined the feasibility and validity of a sequential multiple imputation (MI) method to deal with missing values in the longitudinal HRQoL data from the Scandinavian Obesity Surgery Registry. All patients in the SOReg who received bariatric surgery between 1 January 2011 and 31 March 2019 (n = 47,653) were included for the descriptive analysis and missingness pattern exploration. The patients who had completed the short-form 36 (SF-36) at baseline (year 0), and one-, two-, and five-year follow-ups were included (n = 3957) for the missingness pattern simulation and the sequential MI analysis. Eleven items of the SF-36 were selected to create the six domains of SF-6D, and the SF-6D utility index of each patient was calculated accordingly. The multiply-imputed variables in previous year were used as input to impute the missing values in later years. The performance of the sequential MI was evaluated by comparing the actual values with the imputed values of the selected SF-36 items and index at all four time points. At the baseline and year 1, where missing proportions were about 20% and 40%, respectively, there were no statistically significant discrepancies between the distributions of the actual and imputed responses (all p-values > 0.05). In year 2, where the missing proportion was about 60%, distributions of the actual and imputed responses were consistent in 9 of the 11 SF-36 items. However, in year 5, where the missing proportion was about 80%, no consistency was found between the actual and imputed responses in any of the SF-36 items. Relatively high missing proportions in HRQoL data are common in clinical registries, which brings a challenge to analyzing the HRQoL of longitudinal cohorts. The experimental sequential multiple imputation method adopted in the current study might be an ideal strategy for handling missing data (even though the follow-up survey had a missing proportion of 60%), avoiding significant information waste in the multivariate analysis. However, the imputations for data with higher missing proportions warrant more research.

Translation and cultural adaptation of the Integrated Palliative care Outcome Scale for Dementia (IPOS-Dem) to Swedish.

INTRODUCTION: Systematic assessment tools are helpful for improving and maintaining quality of care. The Integrated Palliative care Outcome Scale (IPOS) was developed for systematic assessment of persons receiving palliative care in a patient-centred way. A version of this tool, the Integrated Palliative care Outcome Scale for Dementia (IPOS-Dem), has been developed for patients with dementia. The aim of this study was to develop a version of the IPOS-Dem translated into Swedish and culturally adapted to a Swedish care setting. METHODS: Forward and backward translations from English into Swedish were performed to develop a first Swedish version. This version was modified for clarity and cultural adaptation based on 13 interviews with nurses and assistant nurses working in geriatrics and dementia care homes. RESULTS: The interview process revealed several issues with the first version that emerged from the translation process. This was changed and further tested to work well, resulting in the final version of the Swedish IPOS-Dem. The tool was perceived as clinically useful but somewhat overlapping with already implemented tools for assessing behavioural and psychological symptoms in dementia. CONCLUSION: The Swedish version of the IPOS-Dem can now be used as a tool for assessing palliative care related problems and concerns for persons with advanced dementia. Future studies can focus on implementation as well as examining validity and reliability of this tool in a Swedish context.

Reference data among general population and known-groups validity among hypertensive population of the EQ-5D-5L in Vietnam.

PURPOSE: This study aims to provide EQ-5D-5L population norms among the general population in Vietnam and to test EQ-5D-5L' construction validity among people living with hypertension there. METHODS: Descriptive statistics of the five dimensions and five levels, EQ-VAS and EQ-5D-5L indexes were categorised into gender and age groups for the EQ-5D-5L population norms. Known-groups testing was set for lower EQ-5D-5L outcomes among people who were aware of their hypertensive status, females, people with more comorbidities, less education, older ages, and higher body mass indexes. Level of confident interval was 95%. RESULTS: The mean EQ-VAS and EQ-5D-5L indexes were 81.10 (SD: 13.35) and 0.94 (SD: 0.09) among the general population. The EQ-5D-5L outcomes were better among younger people, males, people with more education, employees, and single people. Respondents reported fewer problems with self-care and usual activities and tend to have problems at higher levels across older ages. The known-group testing showed statistically significant results. The mean EQ-VAS and EQ-5D-5L indexes of people in the diagnosed hypertensive group (71.48 and 0.94, respectively) were statistically significantly smaller than they were in the non-hypertensive and undiagnosed hypertensive group (76.65 and 0.97; 76.95 and 0.96 accordingly). Statistically significant associations of lower EQ-5D-5L indexes and EQ-VAS were found among people diagnosed for hypertension, people suffering from an incremental comorbidity, and obese people. CONCLUSION: This study has provided EQ-5D-5L population norms for the general population and evidence for known-groups validity of the EQ-5D-5L instrument among hypertensive people in Vietnam.

The characteristics of stroke and its rehabilitation in Northern Tanzania.

BACKGROUND: Stroke causes great suffering and severe disability worldwide, and rehabilitation following a stroke seeks to restore lost functions. The extent to which stroke patients get access to rehabilitation in Tanzania is not well estimated, and drawing a current picture of the rehabilitation services for these persons is the first step in developing a more effective rehabilitation model in the country. OBJECTIVE: The objective of this study was to establish the characteristics of stroke and its rehabilitation at the Kilimanjaro Christian Medical Centre (KCMC), a consultant referral hospital in northern Tanzania. METHODS: This was a records-based descriptive study in which demographic, clinical, and rehabilitation information of stroke patients admitted to the KCMC between January 2012 and December 2015 was collected and audited. The means, percentages, and proportions were used to summarise the demographic, clinical, and rehabilitation patterns using SPSS version 24.0 software. The chi-squared statistic was used to examine the relationships between categorical variables, and a p-value<0.05 was considered statistically significant. RESULTS: Of the 17,975 patients admitted to the KCMC during the period of the study, 753 (4.2%) had suffered a stroke, with a mean age of 68.8 ± 16.4 years. The predominant cause of stroke was hypertension, which accounted for 546 (72.5%) patients. A total of 357 (47.4%) patients had various forms of rehabilitation during the admission to hospital. Following a discharge home 240 (31.9%) patients did not return to the hospital for the continuation of rehabilitation. CONCLUSION: Stroke patients at the KCMC lack access to rehabilitation therapies. Insufficient access to rehabilitation therapies may warrant the need to explore alternative approaches such as tele-rehabilitation technologies in Tanzania.

Sustainable Behavior Change for Health Supported by Person-Tailored, Adaptive, Risk-Aware Digital Coaching in a Social Context: Study Protocol for the STAR-C Research Programme.

Introduction: The Västerbotten Intervention Programme (VIP) in the Region Västerbotten Sweden is one of the very few cardiovascular disease (CVD) prevention programmes globally that is integrated into routine primary health care. The VIP has been shown as a cost-effective intervention to significantly reduce CVD mortality. However, little is known about the effectiveness of a digital solution to tailor risk communication strategies for supporting behavioral change. STAR-C aims to develop and evaluate a technical platform for personalized digital coaching that will support behavioral change aimed at preventing CVD. Methods: STAR-C employs a mixed-methods design in seven multidisciplinary projects, which runs in two phases during 2019-2024: (i) a formative intervention design and development phase, and (ii) an intervention implementation and evaluation phase. In the 1st phase, STAR-C will model the trajectories of health behaviors and their impact on CVDs (Project 1), evaluate the role of the social environment and social networks on behavioral change (Project 2) and assess whether and how social media facilitates the spread of health information beyond targeted individuals and stimulates public engagement in health promotion (Project 3). The findings will be utilized in carrying out the iterative, user-centered design, and development of a person-tailored digital coaching platform (Project 4). In the 2nd phase, STAR-C will evaluate the implementation of the coaching programme and its effectiveness for promoting behavioral change and the spreading of health information across social networks and via social media (Project 5). The cost-effectiveness (Project 6) and ethical issues (Project 7) related to the coaching programme intervention will be evaluated. Discussion: The STAR-C research programme will address the knowledge and practice research gaps in the use of information technologies in health promotion and non-communicable disease (NCD) prevention programmes in order to narrow the health inequality gaps. Ethics: STAR-C has received approval from the Swedish Ethical Review Authority (Dnr. 2019-02924;2020-02985). Dissemination: The collaboration between Umeå University and Region Västerbotten will ensure the feasibility of STAR-C in the service delivery context. Results will be communicated with decision-makers at different levels of society, stakeholders from other regions and healthcare professional organizations, and through NGOs, local and social media platforms.

Quality of life of persons with traumatic spinal cord injury in rural Kilimanjaro, Tanzania: a community survey.

AIM: To describe the quality of life of persons with traumatic spinal cord injury (TSCI) in a rural area of a low-income country. METHODS: This was a cross-sectional descriptive study in which snowballing was used to identify persons with TSCI in their homes. A Kiswahili version of the short version of the World Health Organization quality of life questionnaire was used for data collection. Data were analyzed descriptively and independent samples t-tests were used to calculate the difference in the mean scores between groups. RESULTS: Eighty persons with TSCI with a mean age of 42.29 ± 11.4 years were identified, 68.8% of whom were males. The highest scoring domains were psychological (12.76 ± 2.55) and social relationships (12.62 ± 2.95). The lowest scores were for physical (11.48 ± 2.74) and environment (9.59 ± 2.68) domains. Significantly higher scores were associated with younger age in: physical (0.05), social relationships (0.01), and environment (0.02) domains (p value < 0.05). CONCLUSIONS: Persons with TSCI in the Kilimanjaro rural area registered a relatively low quality of life in which the most affected domains are physical health and environment.Implications for rehabilitationQuality of life is the ultimate goal in the rehabilitation of persons with any irreversible disability such as spinal cord injury.It is important for rehabilitation professionals to know which domains of quality of life are most affected among persons with spinal cord injury.Rehabilitation professionals ought to understand and address physical health and environmental issues that affect persons with traumatic spinal cord injury in rural resource-constrained areas.Addressing physical health and environmental challenges for persons with spinal cord injury in resource-constrained rural areas require involvement of the family, rehabilitation personnel, policy makers, and the community.

A cost-utility analysis of multimodal pain rehabilitation in primary healthcare.

OBJECTIVES: Multimodal rehabilitation programs (MMRPs) have been shown to be both cost-effective and an effective method for managing chronic pain in specialist care. However, while the vast majority of patients are treated in primary healthcare, MMRPs are rarely practiced in these settings. Limited time and resources for everyday activities alongside the complexity of chronic pain makes the management of chronic pain challenging in primary healthcare and the focus is on unimodal treatment. In order to increase the use of MMRPs incentives such as cost savings and improved health status in the patient group are needed. The aim of this study was to evaluate the cost-effectiveness of MMRPs for patients with chronic pain in primary healthcare in two Swedish regions. The aim of this study was to evaluate the cost-effectiveness of MMRPs at one-year follow-up in comparison with care as usual for patients with chronic pain in primary healthcare in two Swedish regions. METHODS: A cost-utility analysis was performed alongside a prospective cohort study comparing the MMRP with the alternative of continuing with care as usual. The health-related quality of life (HRQoL), using EQ5D, and working situation of 234 participants were assessed at baseline and one-year follow-up. The primary outcome was cost per quality-adjusted life year (QALY) gained while the secondary outcome was sickness absence. An extrapolation of costs was performed based on previous long-term studies in order to evaluate the effects of the MMRP over a five-year time period. RESULTS: The mean (SD) EQ5D index, which measures HRQoL, increased significantly (p<0.001) from 0.34 (0.32) to 0.44 (0.32) at one-year follow-up. Sickness absence decreased by 15%. The cost-utility analysis showed a cost per QALY gained of 18 704 € at one-year follow-up. CONCLUSIONS: The results indicate that the MMRP significantly improves the HRQoL of the participants and is a cost-effective treatment for patients with chronic pain in primary healthcare when a newly suggested cost-effectiveness threshold of 19 734 € is implemented. The extrapolation indicates that considerable cost savings in terms of reduced loss of production and gained QALYs may be generated if the effects of the MMRP are maintained beyond one-year follow-up. The study demonstrates potential benefits of MMRPs in primary healthcare for both the patient with chronic pain and the society as a whole. The cost-effectiveness of MMRPs in primary healthcare has scarcely been studied and further long-term studies are needed in these settings.

Factors contributing to the uptake of childhood vaccination in Galkayo District, Puntland, Somalia.

BACKGROUND: As in many Sub-Saharan African countries, the health system in Somalia is not operating at the capacity needed to lift childhood vaccination coverage to ninety percent or above, as recommended by United Nations Children's Fund. Current national estimates of coverage for the six major vaccine preventable childhood diseases range from thirty to sixty percent. Infectious disease outbreaks continue to pose significant challenges for the country's health authorities. OBJECTIVE: This important qualitative study, conducted in Galkayo District, Somalia, investigates limiting factors associated with childhood vaccination uptake from the perspective of both communities and health care workers. METHODS: Qualitative information was collected through six focus group discussions with parents (n = 48) and five one-to-one interviews with health workers (n = 15) between March and May 2017, in three settings in the Galkayo District - Galkayo city, Bayra and Bacadwayn. RESULTS: From a health system perspective, the factors are: awareness raising, hard to reach areas, negative attitudes and perceived knowledge of health workers, inadequate supplies and infrastructure, and missed vaccination opportunities. From the perspective of individuals and communities the factors are: low trust in vaccines, misinterpretation of religious beliefs, vaccine refusals, Somalia's patriarchal system and rumours and misinformation. Parents mostly received immunization information from social mobilizers and health facilities. Fathers, who are typically family decision-makers, were poorly informed. The findings highlight the need for in-service training to enable health workers to improve communication with parents, particularly fathers, peripheral communities and local religious leaders. CONCLUSIONS: Enhancing knowledge and awareness of vaccination among parents is crucial. Fathers' involvement is lacking. This may be boosted by highlighting fathers' obligation to protect their children's health through vaccination. It is also important that men engage with the wider community in decision-making and advance towards the global vaccination targets.

Patient perspectives on interventional pain management: thematic analysis of a qualitative interview study.

BACKGROUND: Chronic pain is a widespread problem that is usually approached by focusing on its psychological aspects or on trying to reduce the pain from the pain generator. Patients report that they feel responsible for their pain and that they are disempowered and stigmatized because of it. Here, we explored interventional pain management from the patient's perspective to understand the process better. METHODS: A purposive sample of 19 subjects was interviewed by an independent interviewer. The interviews were transcribed into text and thematic analysis was performed. RESULTS: The subjects' perceptions covered three key themes: themselves as objects; the caregivers, including the process of tests and retests, the encounters and interactions with professionals, and the availability of the caregivers; and finally the outcomes, including the results of the tests and treatments and how these inspired them to think of other people with pain. Linking these themes, the subjects reported something best described as "gained empowerment" during interventional pain management; they were feeling heard and seen, they gained knowledge that helped them understand their problem better, they could ask questions and receive answers, and they felt safe and listened to. CONCLUSIONS: Many of the themes evolved in relation to the subjects' contact with the healthcare services they received, but when the themes were merged and structured into the model, a cohesive pattern of empowerment appeared. If empowerment is a major factor in the positive effects of interventional pain management, it is important to facilitate and not hinder empowerment. TRIAL REGISTRATION: Clinicaltrials.gov 2013-04-24 (Protocol ID SE-Dnr-2012-446-31 M-3, ClinicalTrials ID NCT01838603 ).

Cost-Effectiveness of Rheumatic Heart Disease Echocardiographic Screening in Brazil: Data from the PROVAR+ Study: Cost-effectiveness of RHD screening in Brazil.

Introduction: In recent years, new technologies - noticeably ultra-portable echocardiographic machines - have emerged, allowing for Rheumatic Heart Disease (RHD) early diagnosis. We aimed to perform a cost-utility analysis to assess the cost-effectiveness of RHD screening with handheld devices in the Brazilian context. Methods: A Markov model was created to assess the cost-effectiveness of one-time screening for RHD in a hypothetical cohort of 11-year-old socioeconomically disadvantaged children, comparing the intervention to standard care using a public perspective and a 30-year time horizon. The model consisted of 13 states: No RHD, Undiagnosed Asymptomatic Borderline RHD, Diagnosed Asymptomatic Borderline RHD, Untreated Asymptomatic Definite RHD, Treated Asymptomatic Definite RHD, Untreated Mild Clinical RHD, Treated Mild Clinical RHD, Untreated Severe Clinical RHD, Treated Severe Clinical RHD, Surgery, Post-Surgery and Death. The initial distribution of the population over the different states was derived from primary echo screening data. Costs of the different states were derived from the Brazilian public health system database. Transition probabilities and utilities were derived from published studies. A discount rate of 3%/year was used. A cost-effectiveness threshold of $25,949.85 per Disability Adjusted Life Year (DALY) averted is used in concordance with the 3x GDP per capita threshold in 2015. Results: RHD echo screening is cost-effective with an Incremental Cost-Effectiveness Ratio of $10,148.38 per DALY averted. Probabilistic modelling shows that the intervention could be considered cost-effective in 70% of the iterations. Conclusion: Screening for RHD with hand held echocardiographic machines in 11-year-old children in the target population is cost-effective in the Brazilian context. Highlights: A cost-effectiveness analysis showed that Rheumatic Heart Disease (RHD) echocardiographic screening utilizing handheld devices, performed by non-physicians with remote interpretation by telemedicine is cost-effective in a 30-year time horizon in Brazil.The model included primary data from the first large-scale RHD screening program in Brazilian underserved populations and costs from the Unified Health System (SUS), and suggests that the Incremental Cost-Effectiveness Ratio of the intervention is considerably below the acceptable threshold for Brazil, even after a detailed sensitivity analysis.Considering the high prevalence of subclinical RHD in Brazil, and the significant economic burden posed by advanced disease, these data are important for the formulation of public policies and surveillance approaches.Cost-saving strategies first implemented in Brazil by the PROVAR study, such as task-shifting to non-physicians, computer-based training, routine use of affordable devices and telemedicine for remote diagnosis may help planning RHD control programs in endemic areas worldwide.

The burden of high workload on the health-related quality of life among home care workers in Northern Sweden.

OBJECTIVE: Previous studies have shown that high workload affects health negatively. However, studies are lacking among home care workers. The aim of this study is to examine the burden of perceived workload on health-related quality of life (HRQoL) among home care workers and to determine whether psychosocial factors modify such a relationship. METHODS: A cross-sectional study was conducted in which 1162 (58% response rate) home care workers participated. The psychosocial factors were measured by QPSnordic. HRQoL was measured by EuroQol 5 dimensions, from which responses were translated into quality-adjusted life year scores (QALY). Propensity scores were used with absolute risk differences (RD). Stratified analysis was used to test the buffer hypothesis of the demand-control-support model. RESULTS: Personnel with a high workload had a statistically significant 0.035 lower QALY than personnel with a normal workload. This difference was also statistically significant for the Visual Analogue Scale (RD 5.0) and the mobility (RD 0.033) and anxiety/depression scales (RD 0.20) dimensions of EQ-5D. For QALY, the effect of a high workload compared to a normal workload was higher, with low (RD 0.045, significant) compared with high (RD 0.015, non-significant) social support; while it was similar, and non-significant results, for low and high control. CONCLUSIONS: Our study shows that lowered work burden would be beneficial for home care personnel. Furthermore, our results suggest that interventions aimed at increasing social support could reduce work-related illness.

An EQ-5D-5L Value Set for Vietnam.

PURPOSE: The objective of this study was to develop an EQ-5D-5L value set based on the health preferences of the general adult population of Vietnam. METHODS: The EQ-VT protocol version 2.1 was applied. Multi-stage stratified cluster sampling was employed to recruit a nationally representative sample. Both composite time trade-off (C-TTO) and discrete choice experiment (DCE) methods were used. Several modelling approaches were considered including hybrid; tobit; panel and heteroscedastic models. First, models using C-TTO or DCE data were tested separately. Then possibility of combining the C-TTO and DCE data was examined. Hybrid models were tested if it was sensible to combine both types of data. The best-performing model was selected based on both the consistency of the results produced and the degree to which models used all the available data. RESULTS: Data from 1200 respondents representing the general Vietnamese adult population were included in the analyses. Only the DCE Logit model and the regular Hybrid model that uses all available data produced consistent results. As the priority was to use all available data if possible, the hybrid model was selected to generate the Vietnamese value set. Mobility had the largest effect on health state values, followed by pain/discomfort, usual activities, anxiety/depression and self-care. The Vietnam values ranged from - 0.5115 to 1. CONCLUSION: This is the first value set for EQ-5D-5L based on social preferences obtained from a nationally representative sample in Vietnam. The value set will likely play a key role in economic evaluations and health technology assessments in Vietnam.

Does unemployment contribute to poorer health-related quality of life among Swedish adults?

BACKGROUND: Previous studies have shown that unemployment has negative impacts on various aspects of health. However, little is known about the effect of unemployment on health-related quality of life. Our aim was to examine how unemployment impacts upon health-related quality of life among Swedish adults, and to investigate these effects on population subgroups defined by education level, marital status, previous health, and gender. METHODS: As part of a cross-sectional study, a questionnaire was sent to 2500 randomly selected individuals aged 20 to 64 years living in Sweden in 2016. The questionnaire included the EuroQol 5 dimensions (EQ-5D) instrument and was answered by 967 individuals (39%). Quality-adjusted life year (QALY) scores were derived from the EQ-5D responses. Of the respondents, 113 were unemployed and 724 were employed. We used inverse probability-weighted propensity scores in our analyses to estimate a risk difference. Gender, age, education level, marital status, and previous health were used as covariates in our analyses. RESULTS: There was a statistically significant lower QALY score by 0.096 points for the unemployed compared to the employed. There were also statistically significant more problems due to unemployment for usual activities (6.6% more), anxiety/depression (23.6% more), and EQ-5D's Visual Analogue Scale (7.5 point lower score). Grouped analyses indicated a larger negative health effect from becoming unemployed for men, those who are married, and young individuals. CONCLUSIONS: In our study, we show that the health deterioration from unemployment is likely to be large, as our estimated effect implies an almost 10% worse health (in absolute terms) from being unemployed compared to being employed. This further highlights that unemployment is a public health problem that needs more focus. Our study also raises further demands for determining for whom unemployment has the most negative effects and thus suggesting groups of individuals who are in greatest need for labor market measures.

Traumatic spinal cord injury in the north-east Tanzania - describing incidence, etiology and clinical outcomes retrospectively.

BACKGROUND: Causes, magnitude and consequences of traumatic spinal cord injury depend largely on geography, infrastructure, socioeconomic and cultural activities of a given region. There is a scarcity of literature on profile of traumatic spinal cord injury to inform prevention and rehabilitation of this health condition in African rural settings, particularly Tanzania. OBJECTIVE: To describe the incidence, etiology and clinical outcomes of traumatic spinal cord injury and issues related to retrospective study in underdeveloped setting. METHODS: Records for patients with traumatic spinal cord injury for five consecutive years (2010-2014) were obtained retrospectively from the admission wards and health records archives of the Kilimanjaro Christian Medical Center. Sociodemographic, cause, complications and patients' condition on discharge were recorded and analyzed descriptively. RESULTS: The admission books in the wards registered 288 new traumatic spinal cord injury cases from January 2010 to December 2014. Of the 288 cases registered in the books, 224 were males and 64 females with mean age 39.1(39.1 ± 16.3) years and the majority of individuals 196(68.1%) were aged between 16 and 45 years. A search of the hospital archives provided 213 full patient records in which the leading cause of injury was falls 104(48.8%) followed by road traffic accidents 73(34.3%). Cervical 81(39.9%) and lumbar 71(34.74%) spinal levels were the most affected. The annual incidence for the Kilimanjaro region (population 1,640,087) was estimated at more than 26 persons per million population. The most documented complications were pressure ulcers 42(19.7%), respiratory complications 32(15.0%) and multiple complications 28(13.1%). The mean length of hospital stay was 64.2 ± 54.3 days and the mortality rate was 24.4%. CONCLUSION: Prevention of traumatic spinal cord injury in North-east Tanzania should consider falls (particularly from height) as the leading cause, targeting male teenagers and young adults. Pressure ulcers, respiratory complications, in-hospital mortality and availability of wheelchairs should be addressed.