The quality of patient care in oncology departments in Karachi, Pakistan: patients' perceptions.

PURPOSE: This study aims to assess the quality of care among adult oncology patients in tertiary care hospitals in Karachi by using an international standard of quality of care and to identify domains where improvement is needed. DESIGN/METHODOLOGY/APPROACH: This is a cross-sectional study carried out at two tertiary care hospitals of Karachi, Pakistan, belonging to private and public sector, respectively, between February and April 2018. Face-to-face interviews were conducted using a modified questionnaire having five-point Likert scale questions regarding satisfaction of patients with doctors, nursing staff, information provided and the hospital standards. SPSS 20 was used for statistical analysis, and the results were expressed using mean, frequencies, percentages and p-values. FINDINGS: The authors approached 415 patients, out of which 389 patients agreed to participate in the study. For both hospitals, the lowest mean scores were for sections pertaining to satisfaction with psychosocial support and information provided. The mean satisfaction score of patients from the private hospital were found to be significantly higher as compared to patients from the public hospital for all domains of patient care (p-value < 0.01 using t-test for two independent samples). The data showed an increasing trend of "satisfied" responses as the household income increased. RESEARCH LIMITATIONS/IMPLICATIONS: A comparative study should be conducted with the aim of pinpointing the differences in areas in which there is a significant difference in positive satisfaction levels between private and public sectors. Similar research could also be expanded adding other variables that affect quality of care such as doctor's approach to their patients, time given during each consultation and patient's understanding of doctor's knowledge. Further studies can be done to bridge the gaps between what a doctor views as standard care and what the patient knows will help them receive a more holistic approach to care. PRACTICAL IMPLICATIONS: Assessing the quality of care helps determine gaps in care and allocating health resources accordingly. In clinical practice, emphasis needs to be given on increased duration and improved quality of patient counselling to improve the low satisfaction levels of patients regarding the psychosocial support. Addressing patients' concerns should be made part of clinical teaching from an undergraduate level. As far as patient access to doctors of the specific speciality is concerned, hospital managements should adopt systems to ensure continuum of care and come up with mechanisms to bridge the discrepancy between a patient's needs and doctor availability. SOCIAL IMPLICATIONS: After being identified as a major deficiency, training doctors in the sensitivities of the population and demographics, especially with respect to socio-economic statuses, can aid in enhancing patient satisfaction to the treatment. Implementation of patient-centred care leads to greater satisfaction with care, which, in turn, increases a patient's self efficacy in managing important aspects of their care and improves health care-related quality of life. ORIGINALITY/VALUE: Cancer patients have long-term exposure to the hospital environment. A patient's satisfaction with the quality of care is an important determinant in patient compliance to the treatment protocol and required hospital visits. There is a dearth of research on the outpatient quality of care in the oncology departments in Karachi. This study provides an overview of the quality of care available to cancer patients in Karachi both in public and private sectors. The results of our study identify the gaps in the quality of care being provided to the patients in a developing country like Pakistan, which can be used to improve the quality of care, leading to better patient outcomes.

High mortality rates for very low birth weight infants in developing countries despite training.

OBJECTIVE: The goal was to determine the effect of training in newborn care and resuscitation on 7-day (early) neonatal mortality rates for very low birth weight (VLBW) infants. The study was designed to test the hypothesis that these training programs would reduce neonatal mortality rates for VLBW infants. METHODS: Local instructors trained birth attendants from 96 rural communities in 6 developing countries in protocol and data collection, the World Health Organization Essential Newborn Care (ENC) course, and a modified version of the American Academy of Pediatrics Neonatal Resuscitation Program (NRP), by using a train-the-trainer model. To test the impact of ENC training, data on infants of 500 to 1499 g were collected by using a before/after, active baseline, controlled study design. A cluster-randomized, controlled trial design was used to test the impact of the NRP. RESULTS: A total of 1096 VLBW (500-1499 g) infants were enrolled, and 98.5% of live-born infants were monitored to 7 days. All-cause, 7-day neonatal mortality, stillbirth, and perinatal mortality rates were not affected by ENC or NRP training. CONCLUSIONS: Neither ENC nor NRP training of birth attendants decreased 7-day neonatal, stillbirth, or perinatal mortality rates for VLBW infants born at home or at first-level facilities. Encouragement of delivery in a facility where a higher level of care is available may be preferable when delivery of a VLBW infant is expected.

Newborn-care training and perinatal mortality in developing countries.

BACKGROUND: Of the 3.7 million neonatal deaths and 3.3 million stillbirths each year, 98% occur in developing countries. An evaluation of community-based interventions designed to reduce the number of these deaths is needed. METHODS: With the use of a train-the-trainer model, local instructors trained birth attendants from rural communities in six countries (Argentina, Democratic Republic of Congo, Guatemala, India, Pakistan, and Zambia) in the World Health Organization Essential Newborn Care course (which focuses on routine neonatal care, resuscitation, thermoregulation, breast-feeding, "kangaroo" [skin-to-skin] care, care of the small baby, and common illnesses) and (except in Argentina) in a modified version of the American Academy of Pediatrics Neonatal Resuscitation Program (which teaches basic resuscitation in depth). The Essential Newborn Care intervention was assessed among 57,643 infants with the use of a before-and-after design. The Neonatal Resuscitation Program intervention was assessed as a cluster-randomized, controlled trial involving 62,366 infants. The primary outcome was neonatal death in the first 7 days after birth. RESULTS: The 7-day follow-up rate was 99.2%. After birth attendants were trained in the Essential Newborn Care course, there was no significant reduction from baseline in the rate of neonatal death from all causes in the 7 days after birth (relative risk with training, 0.99; 95% confidence interval [CI], 0.81 to 1.22) or in the rate of perinatal death; there was a significant reduction in the rate of stillbirth (relative risk with training, 0.69; 95% CI, 0.54 to 0.88; P=0.003). In clusters of births in which attendants had been randomly assigned to receive training in the Neonatal Resuscitation Program, as compared with control clusters, there was no reduction in the rates of neonatal death in the 7 days after birth, stillbirth, or perinatal death. CONCLUSIONS: The rate of neonatal death in the 7 days after birth did not decrease after the introduction of Essential Newborn Care training of community-based birth attendants, although the rate of stillbirths was reduced. Subsequent training in the Neonatal Resuscitation Program did not significantly reduce the mortality rates. (ClinicalTrials.gov number, NCT00136708.)

Anemia prevalence and risk factors in pregnant women in an urban area of Pakistan.

BACKGROUND: Anemia affects almost two-thirds of pregnant women in developing countries and contributes to maternal morbidity and mortality and to low birthweight. OBJECTIVE: To determine the prevalence of anemia and the dietary and socioeconomic factors associated with anemia in pregnant women living in an urban community setting in Hyderabad, Pakistan. METHODS: This was a prospective, observational study of 1,369 pregnant women enrolled at 20 to 26 weeks of gestation and followed to 6 weeks postpartum. A blood sample was obtained at enrollment to determine hemoglobin levels. Information on nutritional knowledge, attitudes, and practice and dietary history regarding usual food intake before and during pregnancy were obtained by trained interviewers within 1 week of enrollment. RESULTS: The prevalence of anemia (defined by the World Health Organization as hemoglobin < 11.0 g/dL) in these subjects was 90.5%; of these, 75.0% had mild anemia (hemoglobin from 9.0 to 10.9 g/dL) and 14.8% had moderate anemia (hemoglobin from 7.0 to 8.9 g/dL). Only 0.7% were severely anemic (hemoglobin < 7.0 g/ dL). Nonanemic women were significantly taller, weighed more, and had a higher body mass index. Multivariate analysis after adjustment for education, pregnancy history, iron supplementation, and height showed that drinking more than three cups of tea per day before pregnancy (adjusted prevalence odds ratio [aPOR], 3.2; 95% confidence interval [CI], 1.3 to 8.0), consumption of clay or dirt during pregnancy (aPOR, 3.7; 95% CI, 1.1 to 12.3), and never consuming eggs or consuming eggs less than twice a week during pregnancy (aPOR, 1.7; 95% CI, 1.1 to 2.5) were significantly associated with anemia. Consumption of red meat less than twice a week prior to pregnancy was marginally associated with anemia (aPOR, 1.2; 95% CI, 0.8 to 1.8) but was significantly associated with lower mean hemoglobin concentrations (9.9 vs. 10.0 g/dL, p = .05) during the study period. A subanalysis excluding women with mild anemia found similar associations to those of the main model, albeit even stronger. CONCLUSIONS: A high percentage of women at 20 to 26 weeks of pregnancy had mild to moderate anemia. Pica, tea consumption, and low intake of eggs and red meat were associated with anemia. Women of childbearing age should be provided nutritional education regarding food sources of iron, especially prior to becoming pregnant, and taught how food choices can either enhance or interfere with iron absorption.