Chronic hepatitis B management in six South Australian Aboriginal community controlled health services.

BACKGROUND: Chronic hepatitis B is a significant public health issue; however, there is limited understanding of the engagement in primary health care of Aboriginal people living with chronic hepatitis B (CHB). METHODS: To better understand the management of CHB, diagnostic reports and case note audits were conducted in six South Australian Aboriginal community controlled health services. The audits covered the initial assessment, CHB monitoring, and hepatocellular carcinoma screening. The initial assessment was reviewed by auditing client clinical records for the first 12months from the date of diagnosis, whereas CHB monitoring and hepatocellular carcinoma screening were determined by auditing a 12-month sample period (January to December 2019). Associations with CHB monitoring were determined using a Chi-squared test and Fisher's exact test P -values, as appropriate. RESULTS: There were 50 current clients with a diagnosis of CHB at the time of the audit (January 2020). Testing was incomplete for the initial assessment, CHB monitoring and hepatocellular carcinoma screening. There were significant associations between the increased likelihood of accessing monitoring and the number of times a person attended an Aboriginal community controlled health service, accessing care in a more remote region, having a documented recall and having a GP management plan containing CHB. CONCLUSION: Through providing evidence of significant associations between having a recall set and GP management plans with increased uptake of disease monitoring, this study has highlighted areas for improvement in clinical management.

Indicator-activities to apply primary health care principles in national or large-scale community health worker programs in low-and middle-income countries: a Delphi exercise.

INTRODUCTION: Primary Health Care (PHC) gained considerable momentum in the past four decades and led to improved health outcomes across a wide variety of settings. In low-and middle-income countries (LMICs), national or large-scale Community Health Worker Programs (CHWPs) are considered as vehicles to incorporate PHC principles into healthcare provision and are an essential aspect of the PHC approach to achieve health for all and sustainable development goals. The success of CHWPs is rooted in the application of PHC principles. However, there is evidence that shows patchy implementation of PHC principles across national CHWPs in LMICs. This may reflect the lack of information on what activities would illustrate the application of these principles in CHWPs. This study aimed to identify a set of core/indicator-activities that reflect the application of PHC principles by CHWPs in LMICs. METHODS: A two-round modified Delphi study was undertaken with participants who have extensive experience in planning, implementation and evaluation of CHWPs. Survey design and analysis was guided by the four PHC principles namely Universal Health Coverage, Community Participation, Intersectoral Coordination and Appropriateness. Responses were collected using a secure online survey program (survey monkey). In round one, participants were asked to list 'core activities' that would reflect the application of each PHC principle and its sub-attributes and challenges to apply these principles in CHWPs. In round two, participants were asked to select whether they agree or disagree with each of the activities and challenges. Consensus was set a priori at 70% agreement of participants for each question. RESULTS: Seventeen participants from 15 countries participated in the study. Consensus was reached on 59 activities reflecting the application of PHC principles by CHWPs. Based on participants' responses, a set of 29 indicator-activities for the four PHC principles was developed with examples for each indicator-activity. CONCLUSION: These indicator-activities may provide guidance on how PHC principles can be implemented in CHWPs. They can be used in the development and evaluation of CHWPs, particularly in their application of PHC principles. Future research may focus on testing the utility of indicator-activities on CHWPs in LMICs.

Applying Public Health Principles to Better Manage the COVID-19 Pandemic: "Community Participation," "Equity," and "Cultural Sensitivity".

Although coronavirus vaccine roll-out is beginning, standard public health practices will, for most people, remain their first line of protection for some time. Three principles guiding the pandemic control process, namely community participation, promotion of equity, and cultural sensitivity, can help people adhere to public health advice. These three principles can enhance intervention effectiveness, decreasing the rate of infection and protecting human rights, promoting social harmony and preventing unrest.

Health system and quality of care factors contributing to maternal deaths in East Java, Indonesia.

Despite most Indonesian women now receiving antenatal care on the nationally recommended four occasions and being delivered by skilled birth attendants, the nation's maternal mortality ratio (MMR) is estimated as 177 per 100,000 live births. Recent research in a rural district of Indonesia has indicated that poor service quality due to organizational and personnel factors is now a major determinant of this high MMR. The present research is an in-depth analysis of possible health service organizational and quality of care related causes of death among 30 women admitted to a peak referral hospital in a major Indonesian city. Despite their condition being complex or deteriorating, most of these women arrived at the hospital in a state where it was feasible to prevent death with good quality care. Poor application of protocols, poor information flow from frontline hospitals to the peak referral hospital, delays in emergency care, and delays in management of deteriorating patients were the main contributing factors to these deaths. Pyramidal referrals also contributed, as many women were initially referred to hospitals where their condition could not be effectively managed. While generic quality improvement measures, particularly training and monitoring for rigorous application of clinical protocols (including forward planning for deteriorating patients) will help improve the situation, the districts and hospitals need to develop capacity to assess their local situation. Unless local organisational factors, staff knowledge and skill, blood and blood product availability, and local reasons for delays in providing care are identified, it may not be possible to effectively reduce the adverse pregnancy outcomes.

Why snakebite patients in Myanmar seek traditional healers despite availability of biomedical care at hospitals? Community perspectives on reasons.

BACKGROUND: Snakebite is a major public health problem in many developing countries. Farmers are particularly exposed to snakes, and due to their rural location often experience delays in accessing formal healthcare. The reasons to use traditional healers may include difficulties in accessing formal healthcare, certain beliefs about snakes and snake venom, tradition, and trust in the capacity of traditional healers. Traditional healing, however, may have serious consequences in terms of delays or added complications. There is little in-depth current information about the reasons for its continued use for snakebite. As part of a health services development project to improve health outcomes for snakebite patients, community attitudes to the use of traditional healers were explored in the Mandalay region of Myanmar. METHODOLOGY & FINDINGS: With the objective of learning from local communities, information was generated in three communities using participatory appraisal methods with the communities, and focus group discussions with the local healthcare staff. Many snakebite victims in these communities use traditional healing. Reasons include transport difficulties, low cost for traditional healing, inadequacy of anti-snake venom in the formal healthcare sector, and traditional beliefs, as traditional healing practices are rooted in many cultural and traditional factors. The communities reported that even if access to medical care were improved, traditional healing would continue to be used. CONCLUSION: These findings point to the need for working with traditional healers for prevention, appropriate first aid and timely access to effective treatment for snakebite.

'We don't have to go and see a special person to solve this problem': Trauma, mental health beliefs and processes for addressing 'mental health issues' among Sudanese refugees in Australia.

BACKGROUND: The impact of trauma on refugee mental health has been a particular focal point for research and treatment in Western contexts, despite uncertainty about the degree to which this corresponds with refugees' needs, mental health beliefs and healing mechanisms. AIMS: This study explored the mental health beliefs of resettling Sudanese refugees in Australia. METHODS: In-depth qualitative interviews were conducted with Sudanese community representatives and with a range of health and social work professionals who were not necessarily Sudanese. RESULTS: The concept of trauma was not universally considered to be salient for Sudanese refugees. Key informants, especially those in refugee-oriented services, emphasised stoicism and a desire to move forward and questioned the appropriateness of Western psychological therapies. Processes that exist within the family and the Sudanese community to deal with stressors like loss, grief and social isolation were explained. CONCLUSION: Dialogue between services and community members is needed to ensure responses to refugee mental health are sensitive to the diversity of needs and mental health beliefs of refugees. This will enable workers to ascertain how individual refugees understand their experiences of distress or sadness and to determine whether community strategies and/or professional responses are appropriate.

Cooperative medical insurance and the cost of care in Shandong, PR China: perspectives of patients and community members.

This research was conducted to identify the cost of care associated with utilization of village clinics and membership of the New Cooperative Medical Scheme (NCMS) in 2 counties of Shandong province, PR China. A total of 397 community members and 297 patients who used the village clinics were interviewed. The average cost for primary care treatment of 1 episode of illness was about 55 yuan (about US$8). Although more than 50% of people had NCMS membership, many consider the monetary reimbursements as insufficient. The low insurance reimbursement rates and inability to pay out-of-pocket expenses compromise access to care. Delays can cause more serious illnesses with potential to overburden the secondary care at the township and county hospitals. Those rural people who have not yet enjoyed the benefits of China's economic development may not benefit from recent health care reform and finance mechanisms unless schemes such as the NCMS provide more substantial subsidies.

Exploring health professionals' perspectives on factors affecting Iranian hospital efficiency and suggestions for improvement.

While numerous studies have been undertaken in many developed countries and in a few developing countries, there has so far been no systematic attempt to identify factors affecting efficiency in the Iranian hospitals. This study was designed to elicit the perspectives of a group of health professionals and managers so as to analyse factors affecting the efficiency of hospitals owned by the Iranian Social Security Organization (SSO), which is the second largest institutional source of hospital care in that country. This study also aimed to identify actions that would improve efficiency. Using purposive sampling (to identify key informants), interviews with seventeen health professionals and hospital managers involved in the SSO health system were conducted. The respondents identified a number of organizational factors affecting efficiency, particularly the hospital budgeting and payment system used to fund physicians, and the lack of the managerial skills needed to manage complex facilities such as hospitals. The interviewees stressed the necessity for reforms of the regulatory framework to improve efficiency. A few participants recommended the concept of a funder-provider split. The results of this exploratory study have provided meaningful insight into Iranian health professionals views of factors affecting efficiency, and of possible remedial actions. It is expected that the findings will provide guidance for health policy makers and hospital managers in the Iranian SSO to analyse factors affecting efficiency and to identify remedial actions to improve efficiency. Hospitals in other developing countries may be affected by similar factors.

Public health and health services development in postconflict communities: a case study of a safe motherhood project in East Timor.

Armed conflict causes suffering in many countries; it contributes to poor health and hinders health services development. The effects of conflict are evidenced by weakened community structures and can make reconstruction efforts challenging. East Timor has a history of prolonged conflict and saw a resurgence of internal violence in 2006. This participant observation study discusses considerations for implementing public health and health systems development projects in postconflict settings using a case study of a maternal and child health project. It illustrates the importance of appreciating the historical context and community dynamics when implementing development projects. The sequelae of conflict are often characterized by reduced human resource development capacity, distrust of hierarchy, and limited capacity for resource mobilization. Working in such postconflict communities requires flexibility in program design, stronger efforts for community capacity building, and rebuilding trust between various stakeholders.