Factors related to environmental barriers experienced by persons with and without disabilities in diverse African settings.

This paper explores differences in experienced environmental barriers between individuals with and without disabilities and the impact of additional factors on experienced environmental barriers. Data was collected in 2011-2012 by means of a two-stage cluster sampling and comprised 400-500 households in different sites in South Africa, Sudan Malawi and Namibia. Data were collected through self-report survey questionnaires. In addition to descriptive statistics and simple statistical tests a structural equation model was developed and tested. The combined file comprised 9,307 participants. The Craig Hospital Inventory of Environmental Factors was used to assess the level of environmental barriers. Transportation, the natural environment and access to health care services created the biggest barriers. An exploratory factor analysis yielded support for a one component solution for environmental barriers. A scale was constructed by adding the items together and dividing by number of items, yielding a range from one to five with five representing the highest level of environmental barriers and one the lowest. An overall mean value of 1.51 was found. Persons with disabilities scored 1.66 and persons without disabilities 1.36 (F = 466.89, p < .001). Bivariate regression analyses revealed environmental barriers to be higher among rural respondents, increasing with age and severity of disability, and lower for those with a higher level of education and with better physical and mental health. Gender had an impact only among persons without disabilities, where women report more barriers than men. Structural equation model analysis showed that socioeconomic status was significantly and negatively associated with environmental barriers. Activity limitation is significantly associated with environmental barriers when controlling for a number of other individual characteristics. Reducing barriers for the general population would go some way to reduce the impact of these for persons with activity limitations, but additional and specific adaptations will be required to ensure an inclusive society.

Human resources for primary health care in sub-Saharan Africa: progress or stagnation?

BACKGROUND: The World Health Organization defines a "critical shortage" of health workers as being fewer than 2.28 health workers per 1000 population and failing to attain 80% coverage for deliveries by skilled birth attendants. We aimed to quantify the number of health workers in five African countries and the proportion of these currently working in primary health care facilities, to compare this to estimates of numbers needed and to assess how the situation has changed in recent years. METHODS: This study is a review of published and unpublished "grey" literature on human resources for health in five disparate countries: Mali, Sudan, Uganda, Botswana and South Africa. RESULTS: Health worker density has increased steadily since 2000 in South Africa and Botswana which already meet WHO targets but has not significantly increased since 2004 in Sudan, Mali and Uganda which have a critical shortage of health workers. In all five countries, a minority of doctors, nurses and midwives are working in primary health care, and shortages of qualified staff are greatest in rural areas. In Uganda, shortages are greater in primary health care settings than at higher levels. In Mali, few community health centres have a midwife or a doctor. Even South Africa has a shortage of doctors in primary health care in poorer districts. Although most countries recognize village health workers, traditional healers and traditional birth attendants, there are insufficient data on their numbers. CONCLUSION: There is an "inverse primary health care law" in the countries studied: staffing is inversely related to poverty and level of need, and health worker density is not increasing in the lowest income countries. Unless there is money to recruit and retain staff in these areas, training programmes will not improve health worker density because the trained staff will simply leave to work elsewhere. Information systems need to be improved in a way that informs policy on the health workforce. It may be possible to use existing resources more cost-effectively by involving skilled staff to supervise and support lower level health care workers who currently provide the front line of primary health care in most of Africa.

Perceived Barriers for Accessing Health Services among Individuals with Disability in Four African Countries.

There is an increasing awareness among researchers and others that marginalized and vulnerable groups face problems in accessing health care. Access problems in particular in low-income countries may jeopardize the targets set by the United Nations through the Millennium Development Goals. Thus, identifying barriers for individuals with disability in accessing health services is a research priority. The current study aimed at identifying the magnitude of specific barriers, and to estimate the impact of disability on barriers for accessing health care in general. A population based household survey was carried out in Sudan, Namibia, Malawi, and South Africa, including a total of 9307 individuals. The sampling strategy was a two-stage cluster sampling within selected geographical areas in each country. A listing procedure to identify households with disabled members using the Washington Group six screening question was followed by administering household questionnaires in households with and without disabled members, and questionnaires for individuals with and without disability. The study shows that lack of transport, availability of services, inadequate drugs or equipment, and costs, are the four major barriers for access. The study also showed substantial variation in perceived barriers, reflecting largely socio-economic differences between the participating countries. Urbanity, socio-economic status, and severity of activity limitations are important predictors for barriers, while there is no gender difference. It is suggested that education reduces barriers to health services only to the extent that it reduces poverty. Persons with disability face additional and particular barriers to health services. Addressing these barriers requires an approach to health that stresses equity over equality.

Intrauterine growth standards in a developing country: a study of singleton livebirths at 28-42 weeks' gestation.

This study aimed to develop fetal growth charts for the population of Greater Beirut, Lebanon, and compare them with previously established references. A survey of consecutive singleton livebirths admitted to normal nurseries and neonatal intensive care units of major hospitals, through the database project of the National Collaborative Perinatal Neonatal Network was used as a design. The study was conducted in nine major healthcare institutions serving the population of Beirut and its suburbs. A total of 24 767 singleton livebirths delivered between 28 and 42 weeks' gestation, with known data on gender, gestational age and anthropometric characteristics were recorded between 1 April 1999 and 31 March 2002. Growth charts were developed by plotting birthweight, length and head circumference percentiles against gestational age for male and female infants separately. Overall, 1348 (5.4%) pregnancies were delivered before 37 weeks' gestation and 1227 (4.9%) were low birthweight. Male infants were delivered slightly earlier than their female counterparts and the mean birthweight, length and head circumference were consistently higher in males. A total of 2247 (9.1%) infants were small-for-gestational-age, with a male-to-female sex ratio of 1.03. Using previously established growth references that overestimated small-for-gestational-age prevalence resulted in a greater proportion of false positives. The opposite was true for growth references that underestimated small-for-gestational-age prevalence. The current growth charts present useful tools for assessing the general health status of newborn infants delivered at sea level in the urban areas of Lebanon and other East Mediterranean countries.

Cost of work-related injuries in insured workplaces in Lebanon.

OBJECTIVE: To estimate the medical and compensation costs of work-related injuries in insured workplaces in Lebanon and to examine cost distributions by worker and injury characteristics. METHODS: A total of 3748 claims for work injuries processed in 1998 by five major insurance companies in Lebanon were reviewed. Medical costs (related to emergency room fees, physician consultations, tests, and medications) and wage and indemnity compensation costs were identified from the claims. FINDINGS: The median cost per injury was US dollars 83 (mean, US dollars 198; range, US dollars 0-16,401). The overall cost for all 3748 injuries was US dollars 742,100 (76% of this was medical costs). Extrapolated to all injuries within insured workplaces, the overall cost was US dollars 4.5 million a year; this increased to US dollars 10 million-13 million when human value cost (pain and suffering) was accounted for. Fatal injuries (three, 0.1%) and those that caused permanent disabilities (nine, 0.2%) accounted for 10.4% of the overall costs and hospitalized injuries (245, 6.5%) for 45%. Cost per injury was highest among older workers and for injuries that involved falls and vehicle incidents. Medical, but not compensation, costs were higher among female workers. CONCLUSION: The computed costs of work injuries--a fraction of the real burden of occupational injuries in Lebanon--represent a considerable economic loss. This calls for a national policy to prevent work injuries, with a focus on preventing the most serious injuries. Options for intervention and research are discussed.

Work-related injuries in Lebanon: does nationality make a difference?

BACKGROUND: To compare the type, severity, cause, and cost of work-related injuries between Lebanese and non-Lebanese workers in insured workplaces in Lebanon. METHODS: A total of 4,186 claims and medical reports for 3,748 work-related injuries filed in 1998 at five major insurance companies were reviewed. RESULTS: Non-Lebanese workers (46%) were younger (29 vs. 31 years), belonged mainly to the construction sector (62% vs. 29%), and were paid less (365 dollars vs. 438 dollars/month) than Lebanese workers. Non-Lebanese construction workers reported more feet and eye injuries. Falls were more common among Lebanese workers while non-Lebanese workers commonly reported being struck by an object. No differences were noted in the severity of injuries (workdays lost; hospitalization) between the two groups, but, overall cost per injury was higher among the Lebanese workers. CONCLUSIONS: There were no salient differences between Lebanese and non-Lebanese workers regarding severity of work injuries, which may reflect the disparity in access to the Lebanese heath care system by nationality. Syrian migrant workers appear to represent a special group in Lebanon. Additional, in-depth analysis of the social, political, and workplace mechanisms leading to work injuries is recommended.