Classification and design of teledermatology practice: what dermatoses? Which technology to apply?

Dermatologists are mostly confined to urban regions and rural population is deprived of specialist care. Teledermatology Practice (TDP) is a solution to overcome this global problem. Tools for TDP includes video conference, store and forward, hybrid, mobile, satellite communication, integration model, nurse-led teledermatology, teledermatology focusing on difficult-to-manage cases, teledermoscopy, and teledermatopathology with combined applications. This article reviews the feasibility studies focusing teledermatology tools and analyses the possible options in designing TDP. Categorizing dermatoses for TDP depends on the purpose and types of technology. The dermatoses presenting from a remote geographic regions requires any of the following approaches (i) only TDP, (b) initial TDP followed by face-to-face, (iii) initial face-to-face followed by TDP and (iv) only face-to-face examination. The technology should suit the dermatoses, meet the purpose, be cost-effective and provide better management with follow-up care. We recommend store and forward as a basic TDP model as most dermatoses are diagnosed and follow-up care is delivered. Leprosy, pigmented skin lesions, leg ulcers, HIV and endemic dermatoses require screening and triage services using mobile teledermatology. Counselling and education require videoconference. Rural dermatology's camps require satellite communication mounted on a vehicle. Objective assessment (vitiligo and leg ulcer) after treatment requires integration model at a tertiary centre. Difficult-to-manage cases require second opinion using hybrid/store and forward TDP. Lower rural centre are provided with mobile/ store and forward teledermatology services. Selected or major community centre should be equipped with hybrid teledermatology and linked to a tertiary centre. This process helps healthcare administration to plan a TDP to cover all dermatoses, utilizing the available health care professional (HCP) and technology with minimum budget investment.

Community health nursing practices in contexts of poverty, uncertainty and unpredictability: a systematization of personal experiences.

Several years of professional nursing practices, while living in the poorest neighbourhoods in the outlying areas of Brazil's Amazon region, have led the author to develop a better understanding of marginalized populations. Providing care to people with leprosy and sex workers in riverside communities has taken place in conditions of uncertainty, insecurity, unpredictability and institutional violence. The question raised is how we can develop community health nursing practices in this context. A systematization of personal experiences based on popular education is used and analyzed as a way of learning by obtaining scientific knowledge through critical analysis of field practices. Ties of solidarity and belonging developed in informal, mutual-help action groups are promising avenues for research and the development of knowledge in health promotion, prevention and community care and a necessary contribution to national public health programmers.

Community health nursing practices in contexts of poverty, uncertainty and unpredictability: a systematization of personal experiences

Several years of professional nursing practices, while living in the poorest neighbourhoods in the outlying areas of Brazil's Amazon region, have led the author to develop a better understanding of marginalized populations. Providing care to people with leprosy and sex workers in riverside communities has taken place in conditions of uncertainty, insecurity, unpredictability and institutional violence. The question raised is how we can develop community health nursing practices in this context. A systematization of personal experiences based on popular education is used and analyzed as a way of learning by obtaining scientific knowledge through critical analysis of field practices. Ties of solidarity and belonging developed in informal, mutual-help action groups are promising avenues for research and the development of knowledge in health promotion, prevention and community care and a necessary contribution to national public health programmers.

Muitos anos de prática profissional em enfermagem, vivendo nas vizinhanças mais pobres de áreas distantes da região Amazônica brasileira levaram a autora a desenvolver uma melhor compreensão das populações marginalizadas. O cuidado às pessoas com lepra e trabalhadores do sexo de comunidades ribeirinhas tem sido realizado em condições de incerteza, insegurança, imprevisibilidade e violência institucional. A questão levantada é como podemos desenvolver práticas de enfermagem na saúde da comunidade neste contexto. A sistematização de experiências pessoais baseadas na educação popular é usada e analisada como uma maneira de conhecer e obter conhecimento científico através da análise crítica das práticas da área. Laços de solidariedade e pertencimento desenvolvidos em ações de grupos informais de ajuda mútua são caminhos promissores para pesquisa e desenvolvimento do conhecimento em promoção a saúde, prevenção e cuidado à comunidade e uma contribuição necessária para os programas de saúde pública nacional.

Varios años de prácticas profesionales de enfermería, viviendo en los distritos más pobres de las áreas periféricas de la región amazónica de Brasil, llevaron o autor a desarrollar una mejor comprensión de poblaciones marginalizadas. La provisión de cuidados a personas con lepra y trabajadores del sexo en comunidades ribereñas ha sido llevado a cabo en condiciones de incertidumbre, inseguridad, imprevisibilidad y violencia institucional. Se pregunta como podemos desarrollar prácticas de enfermería en salud comunitaria en este contexto. Una sistematización de experiencias personales basada en educación popular es usada y analizada como un método de saber, obteniendo conocimiento científico mediante un análisis crítico de prácticas en el campo. Lazos de solidaridad y pertenencia desarrollados en grupos de acción informales, de ayuda mutua son caminos prometedores para la investigación y el desarrollo de conocimiento en la promoción de la salud, prevención y atención comunitaria y una contribución necesaria a programas nacionales de salud pública.

Cost and cost-effectiveness of increased community and primary care facility involvement in tuberculosis care in Machakos District, Kenya.

SETTING: Machakos District, Kenya, a rural area 50 km east of Nairobi. OBJECTIVE: To assess the cost and cost-effectiveness of new treatment strategies for tuberculosis patients, involving decentralisation of care from hospitals to peripheral health units and the community, compared to the conventional approaches to care used until October 1997. METHODS: Costs were analysed in 1998 US dollars from the perspective of health services, patients, family members and the community, using standard methods. Separate analyses were undertaken for 1) new smear-positive pulmonary patients and 2) new smear-negative and extrapulmonary patients. Cost-effectiveness was calculated as the cost per patient successfully completing treatment (smear-positive cases) and as the cost per patient completing treatment (new smear-negative and extra-pulmonary cases). FINDINGS: The cost per patient treated for new smear-positive patients was dollars 591 with the conventional hospital-based approach to care, and dollars 209 with decentralised care. Costs fell from all perspectives, and by 65% overall. Cost-effectiveness improved by 66%. The cost per patient treated for new smear-negative/extra-pulmonary patients was dollars 311 with the conventional approach to care, and dollars 197 with decentralised care. Costs fell from all perspectives, and cost-effectiveness improved by 61%. CONCLUSION: There is a strong economic case for expansion of decentralisation and strengthened community-based care in Kenya. The National Tuberculosis and Leprosy Control Programme will require new funds for start-up training and community mobilisation costs in order to do this.