Longitudinal study of quality of life among children with acute respiratory infection and cough.

PURPOSE: Acute respiratory infections (ARIs), and associated symptoms such as cough, are frequently experienced among children and impose a burden on families (e.g., use of medical resources and time off work/school). However, there are little data on changes in, and predictors of, quality of life (QoL) over the duration of an ARI with cough (ARIwC) episode. We therefore aimed to determine cough-specific QoL and identify its influencing factors among children with ARIwC, at the time of presentation to a pediatric emergency department (ED), and over the following 4 weeks. METHODS: Data from 283 children aged < 15 years were included in our analyses. We used the validated parent-proxy children's acute cough-specific QoL questionnaire (PAC-QoL) at each time-point. Linear regression and mixed effect modeling were used to identify factors influencing QoL at baseline and over the follow-up period. RESULTS: Median PAC-QoL at baseline was 2.7 (IQR 2.1-3.6) and significantly improved by Day-7 (4.9, IQR 3.8-6.1) and Day-14 (6.59, IQR 5.1-7.0), both p < 0.001. The improvements in median PAC-QoL between Days-14, -21, and -28 were not significant. Regression modeling identified that day-cough severity, night-cough severity, and financial concerns had the highest impact on both baseline, and follow-up, PAC-QoL scores. There were five additional independent significant factors at baseline and six at follow-up. CONCLUSIONS: Quality of life is considerably impaired at presentation to ED, but improves significantly by Days-7 and -14. As cough severity and financial concerns had the highest impact on QoL, effectively managing cough to reduce the clinical and financial burden on children and families is important.

Acceptability of programme budgeting and marginal analysis as a tool for routine priority setting in Indigenous health.

OBJECTIVE: This study aimed to examine the acceptability of programme budgeting and marginal analysis (PBMA) as a tool for priority setting in the Indigenous health sector. METHODS: The study uses a mix of quantitative and qualitative methods. A survey of key decision makers in Indigenous health in Victoria was conducted to assess the acceptability of PBMA as a potential tool for priority setting. Respondents comprised 24 bureaucrats from the Victorian Department of Human Services (DHS) and 26 senior executives from the aboriginal community controlled health sector (ACCHS) in Victoria. The survey instrument included both closed-ended and open-ended questions and was administered face-to-face by a trained researcher in 2007-2008. Closed-ended questions were analysed using descriptive statistics, and content analysis was used for the open-ended ones. RESULTS: The PBMA was well received as having the potential to improve priority setting processes in Indigenous health. Sixty-nine percent of the DHS respondents felt that PBMA was acceptable as a routine decision-making tool, and nearly 80% of ACCHS respondents thought that PBMA was intuitively appealing and would most probably be an acceptable priority setting approach in their organisations. The challenges of using PBMA were related to resource constraints and data intensity. CONCLUSION: Programme budgeting and marginal analysis is potentially acceptable within the ACCHS and was perceived as useful in terms of assisting the decision maker to maximise health outcomes, but data systems need to be re-oriented to address its significant data needs. IMPLICATION: Proper guidelines need to be developed to facilitate PBMA application within the Indigenous-controlled community health sector. Copyright © 2015 John Wiley & Sons, Ltd.

Building evidence for peer-led interventions: assessing the cost of the Adolescent Asthma Action program in Australia.

Asthma is the most common chronic illness among adolescents in Australia. Aboriginal and Torres Strait Islander adolescents, in particular, face substantial inequalities in asthma-related outcomes. Triple A (Adolescent Asthma Action) is a peer-led education intervention, which aims to improve asthma self-management and reduce the uptake of smoking among adolescents. The aim of this study was to determine the cost of implementing the Triple A program in Australia. Standard economic costing methods were used. It involved identifying the resources that were utilised (such as personnel and program materials), measuring them and then valuing them. We later performed sensitivity analysis so as to identify the cost drivers and a stress test to test how the intervention can perform when some inputs are lacking. Results indicate that the estimated cost of implementing the Triple A program in five schools was $41060, assuming that the opportunity cost of all the participants and venues was accounted for. This translated to $8212 per school or $50 per target student. From sensitivity analysis and a stress test, it was identified that the cost of the intervention (in practice) was $14 per student. This appears to be a modest cost, given the burden of asthma. In conclusion, the Triple A program is an affordable intervention to implement in high schools. The potential asthma cost savings due to the program are significant. If the Triple A program is implemented nation-wide, the benefits would be substantial.

Retaining doctors in rural Timor-Leste: a critical appraisal of the opportunities and challenges.

Timor-Leste is in the process of addressing a key issue for the country's health sector: a medical workforce that is too small to provide adequate care. In theory, a bilateral programme of medical cooperation with Cuba created in 2003 could solve this problem. By the end of 2013, nearly 700 new doctors trained in Cuba had been added to Timor-Leste's medical workforce and by 2017 a further 328 doctors should have been trained in the country by Cuban and local health professionals. A few more doctors who have been trained in Indonesia and elsewhere will also soon enter the workforce. It is expected that the number of physicians in Timor-Leste in 2017 will be more than three times the number present in the country in 2003. Most of the new physicians are expected to work in rural communities and support the national government's goal of improving health outcomes for the rural majority. Although the massive growth in the medical workforce could change the way health care is delivered and substantially improve health outcomes throughout the country, there are challenges that must be overcome if Timor-Leste is to derive the maximum benefit from such growth. It appears crucial that most of the new doctors be deployed in rural communities and managed carefully to optimize their rural retention.

Le Timor-Leste s'occupe actuellement d'un problème essentiel du secteur de la santé du pays: l'effectif médical est trop restreint pour pouvoir dispenser des soins adéquats. En théorie, un programme bilatéral de coopération médicale avec Cuba créé en 2003 pourrait résoudre ce problème. À la fin de 2013, près de 700 nouveaux médecins formés à Cuba ont rejoint l'effectif médical du Timor-Leste et d'ici 2017, 328 médecins supplémentaires devraient avoir été formés dans le pays par des professionnels de la santé locaux et cubains. Quelques autres médecins, formés en Indonésie et ailleurs, intégreront bientôt cet effectif médical. On s'attend à ce que le nombre de médecins exerçant dans le Timor-Leste en 2017 soit trois fois supérieur au nombre de médecins présents dans le pays en 2003. La plupart des nouveaux médecins devraient travailler dans les communautés rurales et soutenir l'objectif du gouvernement national d'améliorer l'état de santé de la majorité rurale. Bien que l'augmentation importante de l'effectif médical puisse changer la manière de dispenser les soins de santé et améliorer considérablement la santé dans l'ensemble du pays, des défis doivent être surmontés pour que le Timor-Leste puisse tirer le bénéfice maximal de cette augmentation. Il semble crucial que la majorité des nouveaux médecins soient déployés dans les communautés rurales et gérés soigneusement pour qu'ils restent le plus possible dans les zones rurales.

Timor-Leste se encuentra en proceso de abordar una cuestión clave para el sector sanitario del país: un personal médico demasiado escaso para proporcionar una atención adecuada. En teoría, un programa bilateral de cooperación médica con Cuba, creado en el año 2003, podría solucionar este problema. A finales de 2013, casi 700 médicos nuevos formados en Cuba se unieron al personal médico de Timor-Leste, y se espera que profesionales de la salud nacionales y cubanos formen a otros 328 médicos en el país hasta 2017. En Indonesia y otros lugares han recibido formación algunos médicos más, que se sumarán pronto a este personal. Se espera que el número de médicos en Timor-Leste triplique en el año 2017 el número de médicos existentes en el país en 2003. La mayoría de estos médicos nuevos trabajarán en comunidades rurales y respaldarán el objetivo del gobierno nacional de mejorar los resultados sanitarios de la mayoría rural. Aunque el incremento masivo del personal médico podría cambiar el modo de proporcionar la atención sanitaria y mejorar notablemente los resultados sanitarios en todo el país, hay desafíos que es necesario superar si Timor-Leste pretende obtener el máximo beneficio de dicho crecimiento. Parece fundamental que la mayor parte de los nuevos médicos se despliegue en comunidades rurales y se gestione con gran atención para optimizar su permanencia en dichas zonas.

Priority setting in Indigenous health: assessing priority setting process and criteria that should guide the health system to improve Indigenous Australian health.

INTRODUCTION: The health of Indigenous Australians is worse than that of other Australians. Most of the determinants of health are preventable and the poor health outcomes are inequitable. The Australian Government recently pledged to close that health gap. One possible way is to improve the priority setting process to ensure transparency and the use of evidence such as epidemiology, equity and economic evaluation.The purpose of this research was to elicit the perceptions of Indigenous and non-Indigenous decision-makers on several issues related to priority setting in Indigenous-specific health care services. Specifically, we aimed to:1. identify the criteria used to set priorities in Indigenous-specific health care services;2. determine the level of uptake of economic evaluation evidence by decision-makers and how to improve its uptake; and 3. identify how the priority setting process can be improved from the perspective of decision-makers. METHODS: We used a paper survey instrument, adapted from Mitton and colleagues' work, and a face-to-face interview approach to elicit decision-makers' perceptions in Indigenous-specific health care in Victoria, Australia. We used mixed methods to analyse data from the survey. Responses were summarised using descriptive statistics and content analysis. Results were reported as numbers and percentages. RESULTS: The size of the health burden; sustainability and acceptability of interventions; historical trends/patterns; and efficiency are key criteria for making choices in Indigenous health in Victoria. There is a need for an explicit priority setting approach, which is systematic, and is able to use available data/evidence, such as economic evaluation evidence. The involvement of Indigenous Australians in the process would potentially make the process acceptable. CONCLUSIONS: An economic approach to priority setting is a potentially acceptable and useful tool for Aboriginal Community Controlled Health Services (ACCHS). It has the ability to use evidence and ensure due process at the same time. The use of evidence can ensure that health outcomes for Indigenous peoples can be maximised - hence, increase the potential for 'closing the gap' between Indigenous and other Australians.

Prevalence of Biomarkers and Associated Factors for Chronic Kidney Disease in Adult Diabetic Out-patients in a Tertiary Hospital in Eastern Uganda - a Cross-sectional Study.

Background: Chronic kidney disease (CKD) is one of the most common complications of Diabetes Mellitus (DM). DM contributes to about 66% of CKD cases globally. CKiiiD results in increased morbidity and mortality and advanced stages often require renal replacement therapy that is unaffordable for the majority of the patients. Developing countries have scanty data regarding CKD burden in diabetic patients. OBJECTIVES: This study aimed at determining the prevalence of biomarkers for CKD and associated factors among diabetic patients attending the adult diabetic clinic of Mbale Regional Referral Hospital (MRRH). Methods: A cross-sectional study was conducted at the adult diabetic clinic of Mbale Regional Referral Hospital in Eastern Uganda. 374 adult diabetic patients who consented, were recruited and interviewed. A urine sample for Urine Albumin Creatinine Ratio (UACR) determination and a venous blood sample for measurement of serum creatinine were obtained from each participant. The estimated glomerular filtration rate (eGFR) was determined using the CKD-EPI equation and CKD was staged according to the Kidney Disease Improving Global Outcomes (KDIGO) systems. Results: A total of 318 (85%) participants had an eGFR of ≤ 60mls/min/1.72m2, significant proteinuria, or both. 6.1% were aware. Age, Duration of DM, Hypertension, and Dyslipidemia were associated with CKD biomarkers. Conclusion: There is a high prevalence of biomarkers for CKD among DM patients, the majority of them being undiagnosed. Over half of the DM patients had an eGFR consistent with advanced CKD. Strengthening routine screening for CKD biomarkers and enhancing the DM clinics with more diagnostic resources is recommended.

Exclusive breast-feeding in the first six months: findings from a cross-sectional survey in Mulago hospital, Uganda.

Background: Improving maternal and child health, one of the key UN Sustainable Development Goals (SDGs), is a major challenge in sub-Saharan Africa. Exclusive breast-feeding contributes significantly to child survival and development, but many mothers in Africa do not exclusively breastfeed their infants. This paper reports a study in Mulago hospital in Kampala. The study aims to identify factors influencing mothers' choices of infant feeding practices. Methods: Mixed methods were used. Respondents included 362 lactating mothers and health workers. Participants were who came for treatment were selected using simple random sampling. EpiInfor and SPSS were used for analysing the data and presented as descriptive study. Results: Results indicate that socio-demographic factors including age and education level influence mothers' ability and willingness to breastfeed exclusively for the first six months. Awareness about breast-feeding was mainly obtained from health centres, leaving mothers unable to attend these centres to miss out on vital information about exclusive breast-feeding. Around 43% of health workers were unaware of the country's Young and Infant Feeding Policy Guidelines. Conclusions: To increase the rate of exclusive breast-feeding in Uganda, it is important that community health is strengthened, and health workers are trained on national breast-feeding policies.

Are Antibiotics Prescribed to Inpatients According to Recommended Standard Guidelines in South Sudan? A Retrospective Cross-Sectional Study in Juba Teaching Hospital.

PURPOSE: Antibiotic resistance is spreading at an alarming rate globally, mainly because of antibiotics misuse. The World Health Organization developed guidelines for the rational use of antibiotics to prevent antibiotic misuse and reduce the potential development of antibiotic resistance. Although many countries adhere to these guidelines and have contextualized them to their needs, data on antibiotics use are limited in African countries, particularly in South Sudan. This study explored prescription patterns and use of antibiotics at Juba Teaching Hospital (JTH) to clarify the potential for antibiotic resistance in South Sudan. MATERIALS AND METHODS: We conducted a retrospective, cross-sectional study of archived patient data from 2016 to determine the prevalence of inappropriate antibiotics use at JTH. We used methodology developed in a previous study to assess the appropriate use of antibiotics. The study sample comprised 384 files. After reviewing and cleaning the files, 316 files were included in our analyses. This study was approved by the South Sudan Ministry of Health Ethics Review Board (approval number: MoH/ERB 51/2018) and all procedures were consistent with the Declaration of Helsinki. RESULTS: Antibiotics use was highest in the medical ward (75.4%). Most antibiotics prescriptions were for infectious diseases (23.7%), followed by ailments affecting the digestive system (19.9%). Commonly prescribed antibiotics were ceftriaxone (21.2%) and metronidazole (20.0%). The mean number of antibiotics prescribed per patient encounter was 2.09 (95% confidence interval: 1.98-2.19). Most files (n=233, 70.57%) demonstrated incorrect use of antibiotics with 78.8% (n=249) of prescriptions being inappropriate (misuse). CONCLUSION: This study revealed a high level of inappropriate antibiotics use at JTH despite the existence of local guidelines, which suggested there was an increased risk for antibiotic resistance. Therefore, it is necessary to introduce antibiotic stewardship activity, along with continuous national surveillance. Enforcement of guidelines to reduce irrational antibiotics use may reduce the risk for antibiotic resistance.

Achieving Sustainable Development Goals (SDGs) in Sub-Saharan Africa (SSA): A Conceptual Review of Normative Economics Frameworks.

Background: The health status of the Sub-Saharan African (SSA) countries is well below that of the rest of the world. Coupled with low per capita income, these countries have agreed and committed themselves to raising their health status equitable standard by addressing United Nations (UN) Sustainability Development Goal number 3 (SDG3) by 2030. Addressing SDG3 requires increased and equitable funding for universal health coverage, healthcare infrastructure, efficient resource allocation, improved priority setting, reduction in corruption, and other strategies. However, what is urgently needed to improve priority setting processes or meaningful health system reform, among other things. There is therefore a need for the exploration of the economic and non-economic (which includes social justice) explicit criteria that ought to form the normative framework for Decision Making. These explicit criteria include efficiency, burden of disease, equality (strict egalitarianism), equity, and explicit criteria. Methods: The ultimate aim was to identify explicit values/principles/criteria that can be used to formulate an ideal normative framework to be used to guide decision Making so as to improve SDG3 in SSA. We synthesized selected literature on the normative frameworks for priority setting processes in health in SSA was undertaken, and the explicit criteria which, ought to guide these frameworks were identified. The form of the Social Welfare function and its principles was identified. Results and Conclusions: The framework and its explicit criteria for priority setting in the SSA countries that ought to be adopted in order to improve their SDG3 was identified-Non-Welfarist framework. This framework allows utility, health and other important social values/attributes/principles to enter the normative SWF. It is argued that such a framework ought to be specified empirically and concurrently by the decision-makers and members of the community representatives. Community representatives ought to be recognized as legitimate claimants of the resources determined, and should therefore be allowed to have a role in specifying the arguments in the SWF and what weights to be attached to the stated arguments. This implies that the selection of options in decision-making should focus on maximizing benefit and minimizing the opportunities forgone as stated in the framework.

The Cost of Acute Respiratory Infections With Cough Among Urban Aboriginal and Torres Strait Islander Children.

Introduction: Acute respiratory infections with cough (ARIwC) contribute considerably to childhood morbidity, yet few studies have examined the cost of these illnesses among Australian children. Moreover, of the few studies that have, none are inclusive of Aboriginal and/or Torres Strait Islander children, despite this population experiencing a greater burden of respiratory illnesses. This study aimed to determine the costs of ARIwC among urban Aboriginal and/or Torres Strait Islander children from the perspective of caretakers, the public healthcare system, and employers. Methods: This cost of illness study used data collected from Aboriginal and/or Torres Strait Islander children aged <5 years enrolled in a 12 month prospective cohort study conducted through an urban primary healthcare clinic in Queensland, Australia. Illness-related resource use was collected for each episode of ARIwC reported, and costed at market rates. Linear regression was used to (a) examine cost per episode by season of illness onset and cough duration and (b) examine cost per month of observation by baseline child and family characteristics. Results: During the study period, a total of 264 episodes of ARIwC were reported among 138 children. The total mean cost was estimated to be $AU252 per non-hospitalized episode (95%CI 169-334). Caretakers, the public healthcare system and employers incurred 44, 39, and 17% of costs per episode, respectively. After accounting for months of completed follow-ups, the total mean cost per child per year was estimated to be $991 (95%CI 514-1468). Winter episodes and episodes resulting in chronic cough were associated with significantly higher costs per episode. A prior history of wheezing, connections to traditional lands and parent/guardian belief that antibiotics should be given until symptoms resolved were associated with significantly higher cost per child month of observation. Conclusion: The cost of ARIwC in this predominantly disadvantaged population is substantial, particularly for caretakers and this needs to be considered in both clinical management and public health initiatives. The importance of cultural factors on health and burden of illness should not be overlooked. Further research into the prevention of chronic cough may play an important role in reducing the economic burden of pediatric respiratory infections.

Health professionals' views on the barriers and enablers to evidence-based practice for acute stroke care: a systematic review.

BACKGROUND: Adoption of contemporary evidence-based guidelines for acute stroke management is often delayed due to a range of key enablers and barriers. Recent reviews on such barriers focus mainly on specific acute stroke therapies or generalised stroke care guidelines. This review examined the overall barriers and enablers, as perceived by health professionals which affect how evidence-based practice guidelines (stroke unit care, thrombolysis administration, aspirin usage and decompressive surgery) for acute stroke care are adopted in hospital settings. METHODOLOGY: A systematic search of databases was conducted using MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, Cochrane Library and AMED (Allied and Complementary Medicine Database from 1990 to 2016. The population of interest included health professionals working clinically or in roles responsible for acute stroke care. There were no restrictions to the study designs. A quality appraisal tool for qualitative studies by the Joanna Briggs Institute and another for quantitative studies by the Centre for Evidence-Based Management were used in the present study. A recent checklist to classify barriers and enablers to health professionals' adherence to evidence-based practice was also used. RESULTS: Ten studies met the inclusion criteria out of a total of 9832 search results. The main barriers or enablers identified included poor organisational or institutional level support, health professionals' limited skills or competence to use a particular therapy, low level of awareness, familiarity or confidence in the effectiveness of a particular evidence-based therapy, limited medical facilities to support evidence uptake, inadequate peer support among health professionals', complex nature of some stroke care therapies or guidelines and patient level barriers. CONCLUSIONS: Despite considerable evidence supporting various specific therapies for stroke care, uptake of these therapies is compromised by barriers across organisational, patients, guideline interventions and health professionals' domains. As a result, we recommend that future interventions and health policy directions should be informed by these findings in order to optimise uptake of best practice acute stroke care. Further studies from low- to middle-income countries are needed to understand the barriers and enablers in such settings. TRIAL REGISTRATION: The review protocol was registered in the international prospective register of systematic reviews, PROSPERO 2015 (Registration Number: CRD42015023481 ).