Why is patient safety so hard in low-income countries? A qualitative study of healthcare workers' views in two African hospitals.

BACKGROUND: The views of practitioners at the sharp end of health care provision are now recognised as a valuable source of intelligence that can inform efforts to improve patient safety in high-income countries. Yet despite growing policy emphasis on patient safety in low-income countries, little research examines the views of practitioners in these settings. We aimed to give voice to how healthcare workers in two East African hospitals identify and explain the major obstacles to ensuring the safety of patients in their care. METHODS: We conducted in-depth, face to face interviews with healthcare workers in two East African hospitals. Our sample included a total of 57 hospital staff, including nurses, physicians, technicians, clinical services staff, administrative staff and hospital managers. RESULTS: Hospital staff in low-income settings offered broadly encompassing and aspirational definitions of patient safety. They identified obstacles to patient safety across three major themes: material context, staffing issues and inter-professional working relationships. Participants distinguished between the proximal influences on patient safety that posed an immediate threat to patient care, and the distal influences that generated the contexts for such hazards. These included contexts of severe material deprivation, but also the impact of relational factors such as teamwork and professional hierarchies. Structures of authority, governance and control that were not optimally aligned with achieving patient safety were widely reported. CONCLUSIONS: As in high-income countries, the accounts of healthcare workers in low-income countries provide sophisticated and valuable insights into the challenges of patient safety. Though the impact of resource constraints and weak governance structures are particularly marked in low-income countries, the congruence between accounts of health workers in diverse settings suggest that the origins and solutions to patient safety problems are likely to be similar everywhere and are rooted in human factors, resources, culture and behaviour. While additional resources are essential to patient safety improvement in low-income settings, such resources on their own will not be sufficient to secure the changes needed.

Soil-transmitted helminths in southern highland Rwanda: associated factors and effectiveness of school-based preventive chemotherapy.

OBJECTIVES: Preventive chemotherapy of schoolchildren against soil-transmitted helminths (STHs) is widely implemented in Rwanda. However, data on its actual efficacy are lacking. We assessed prevalence, associated factors and manifestation of STH infection among schoolchildren in southern highland Rwanda as well as cure and reinfection rates. METHODS: Six hundred and twenty-two children (rural, 301; urban, 321) were included preceding the administration of a single dose of 500 mg mebendazole. Before treatment, and after 2 and 15 weeks, STH infection was determined by Kato-Katz smears and by PCR assays for Ascaris lumbricoides. Clinical and anthropometric data, socio-economic status and factors potentially associated with STH infection were assessed. RESULTS: Soil-transmitted helminth (STH) infection was present in 38% of rural and in 13% of urban schoolchildren. Ascaris lumbricoides accounted for 96% of infections. Of these, one-third was detected by PCR exclusively. Factors associated with STH infection differed greatly between rural and urban children. Likewise, STH infection was associated with stunting and anaemia only among urban children. The cure rate after 2 weeks was 92%. Among eight non-cleared A. lumbricoides infections, seven were submicroscopic. Reinfection within 3 months occurred in 7%, but the rate was higher among rural children, and with initially present infection, particularly at comparatively high intensity. CONCLUSIONS: The rural-urban difference in factors associated with STH infection and in reinfection rates highlights the need for targeted interventions to reduce transmission. PCR assays may help in detecting low-level infections persisting after treatment. In southern Rwanda, mebendazole is highly effective against the STH infections predominated by A. lumbricoides.

Age-dependent decline and association with stunting of Giardia duodenalis infection among schoolchildren in rural Huye district, Rwanda.

Giardia duodenalis infection is highly prevalent and a cause of underweight in pre-school children in rural Rwanda. The present study aimed at assessing the age-pattern of Giardia infection and its manifestation in older children, i.e., during school age. Stool samples were collected from 622 schoolchildren at two schools in the Huye district of southern Rwanda (rural, 301; urban, 321) and subjected to G. duodenalis specific PCR assays. Clinical and anthropometric data, socio-economic status and factors potentially associated with G. duodenalis infection were assessed. Of the 622 children (mean age, 10.4 years), 35.7% were infected with G. duodenalis (rural, 43.9%; urban, 28.0%; P<0.0001). Only few indicators of low socio-economic status were found to be associated with infection. In rural but not urban schoolchildren, infection prevalence declined significantly with age. G. duodenalis infection more than doubled the odds of stunting in both rural (adjusted OR, 2.35 (95%CI, 1.25-4.41)) and urban children (adjusted OR, 2.27 (95%CI, 1.01-5.09)). In the study area of rural southern Rwanda, G. duodenalis prevalence among children declined throughout school-age. The data suggest that while lacking overt clinical manifestation at high endemicity, G. duodenalis infection is a common cause of stunting in schoolchildren.