Identifying gaps in the continuum of care for cardiovascular disease and diabetes in two communities in South Africa: Baseline findings from the HealthRise project.

BACKGROUND: The HealthRise initiative seeks to implement and evaluate innovative community-based strategies for diabetes, hypertension and hypercholesterolemia along the entire continuum of care (CoC)-from awareness and diagnosis, through treatment and control. In this study, we present baseline findings from HealthRise South Africa, identifying gaps in the CoC, as well as key barriers to care for non-communicable diseases (NCDs). METHODS: This mixed-methods needs assessment utilized national household data, health facility surveys, focus group discussions, and key informant interviews in Umgungundlovu and Pixley ka Seme districts. Risk factor and disease prevalence were estimated from the South Africa National Health and Nutrition Examination Survey. Health facility surveys were conducted at 86 facilities, focusing on essential intervention, medications and standard treatment guidelines. Quantitative results are presented descriptively, and qualitative data was analyzed using a framework approach. RESULTS: 46.8% of the population in Umgungundlovu and 51.0% in Pixley ka Seme were hypertensive. Diabetes was present in 11.0% and 9.7% of the population in Umgungundlovu and Pixley ka Seme. Hypercholesterolemia was more common in Pixley ka Seme (17.3% vs. 11.1%). Women and those of Indian descent were more likely to have diabetes. More than half of the population was found to be overweight, and binge drinking, inactivity and smoking were all common. More than half of patients with hypertension were unaware of their disease status (51.6% in Pixley ka Seme and 51.3% in Umgungundlovu), while the largest gap in the diabetes CoC occurred between initiation of treatment and achieving disease control. Demand-side barriers included lack of transportation, concerns about confidentiality, perceived discrimination and long wait times. Supply-side barriers included limited availability of testing equipment, inadequate staffing, and pharmaceutical stock outs. CONCLUSION: In this baseline assessment of two South African health districts we found high rates of undiagnosed hypercholesterolemia and hypertension, and poor control of hypercholesterolemia, hypertension, and diabetes. The HealthRise Initiative will need to address key supply- and demand-side barriers in an effort to improve important NCD outcomes.

Public knowledge of cardiovascular disease and response to acute cardiac events in three cities in China and India.

OBJECTIVE: To inform interventions targeted towards reducing mortality from acute myocardial infarction (AMI) and sudden cardiac arrest in three megacities in China and India, a baseline assessment of public knowledge, attitudes and practices was performed. METHODS: A household survey, supplemented by focus group and individual interviews, was used to assess public understanding of cardiovascular disease (CVD) risk factors, AMI symptoms, cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs). Additionally, information was collected on emergency service utilisation and associated barriers to care. RESULTS: 5456 household surveys were completed. Hypertension was most commonly recognised among CVD risk factors in Beijing and Shanghai (68% and 67%, respectively), while behavioural risk factors were most commonly identified in Bangalore (smoking 91%; excessive alcohol consumption 64%). Chest pain/discomfort was reported by at least 60% of respondents in all cities as a symptom of AMI, but 21% of individuals in Bangalore could not name a single symptom. In Beijing, Shanghai and Bangalore, 26%, 15% and 3% of respondents were trained in CPR, respectively. Less than one-quarter of participants in all cities recognised an AED. Finally, emergency service utilisation rates were low, and many individuals expressed concern about the quality of prehospital care. CONCLUSIONS: Overall, we found low to modest knowledge of CVD risk factors and AMI symptoms, infrequent CPR training and little understanding of AEDs. Interventions will need to focus on basic principles of CVD and its complications in order for patients to receive timely and appropriate care for acute cardiac events.

Breast cancer screening in Saudi Arabia: free but almost no takers.

INTRODUCTION: Mammography ensures early diagnosis and a better chance for treatment and recovery from breast cancer. We conducted a national survey to investigate knowledge and practices of breast cancer screening among Saudi women aged 50 years or older in order to inform the breast cancer national health programs. MATERIALS AND METHODS: The Saudi Health Interview Survey is a national multistage survey of individuals aged 15 years or older. The survey included questions on socio-demographic characteristics, tobacco consumption, diet, physical activity, health-care utilization, different health-related behaviors, and self-reported chronic conditions. Female respondents were asked about knowledge and practices of self and clinical breast exams, as well as mammography. RESULTS: Between April and June 2013, a total of 10,735 participants completed the survey. Among respondents, 1,135 were women aged 50 years or older and were included in this analysis. About 89% of women reported not having a clinical breast exam in the past year, and 92% reported never having a mammogram. Women living in Al Sharqia had the highest rate of mammography use. Women who were educated, those who had received a routine medical exam within the last two years, and those who were diagnosed with hypertension were more likely to have had a mammogram in the past two years. DISCUSSION: Our results show very low rates of breast cancer screening in the Kingdom of Saudi Arabia, a country with free health services. This calls for educational campaigns to improve breast cancer screening. Addressing the barriers for breast cancer screening is a public health imperative.

Impact of pharmacist intervention on clinical outcomes in the palliative care setting.

BACKGROUND: Although accepted as an integral part of the interdisciplinary team, pharmacist value in palliative care has predominantly been evaluated by subjective methods. This study was conducted to identify factors that impact physician acceptance of the pharmacist's recommendation and to determine whether acceptance is a significant predictor of clinical outcome. METHODS: As a mandated in-house quality assurance project at Niagara Hospice, Inc, 2 clinical pharmacists tracked each request for pharmacotherapeutic intervention over a 4-month period (April-July 2009). Through retrospective examination of clinical notes, each intervention was reviewed to determine age, gender, death date, presenting symptom, recommending pharmacist, recommendation type, recommendation status (accepted vs declined), and clinical outcome (achieved vs not achieved). RESULTS: Overall, 89.4% of recommendations were accepted, and 79.9% of patients achieved the desired clinical outcome. With the exception of delirium as a presenting symptom (75% accepted vs 90.8% all other symptoms accepted; P = .02), no significant associations were identified between any variable and recommendation acceptance. Multivariate analysis revealed acceptance of the pharmacist's recommendation (OR, 19.0; 95% CI, 7.10-50.93; P < .001), the recommending pharmacist (resident, OR, 2.46; 95% CI, 1.18-5.12; P = .02), and closer proximity to death (day 0-30, OR, 2.79; 95% CI, 1.16-6.70; P = .02) to be significant predictors of achieving the desired clinical outcome. CONCLUSION: None of the included variables significantly influenced the physician's decision to accept or decline the pharmacist's recommendation. Acceptance of the pharmacist's recommendation was significantly associated with the strongest predictor of the patient achieving the desired clinical outcome.