Community- vs. hospital-based management of multidrug-resistant TB in Pakistan.

BACKGROUND Multidrug-resistant TB (MDR-TB) treatment takes 18-24 months and is complex, costly and isolating. We provide trial evidence on the WHO Pakistan recommendation for community-based care rather than hospital-based care.METHODS Two-arm, parallel-group, superiority trial was conducted in three programmatic management of drug-resistant TB hospitals in Punjab and Sindh Provinces, Pakistan. We enrolled 425 patients with MDR-TB aged >15 years through block randomisation in community-based care (1-week hospitalisation) or hospital-based care (2 months hospitalisation). Primary outcome was treatment success.RESULTS Among 425 patients with MDR-TB, 217 were allocated to community-based care and 208 to hospital-based care. Baseline characteristics were similar between the community and hospitalised arms, as well as in selected sites. Treatment success was 74.2% (161/217) under community-based care and 67.8% (141/208) under hospital-based care, giving a covariate-adjusted risk difference (community vs. hospital model) of 0.06 (95% CI -0.02 to 0.15; P = 0.144).CONCLUSIONS We found no clear evidence that community-based care was more or less effective than hospital-based care model. Given the other substantial advantages of community-based care over hospital based (e.g., more patient-friendly and accessible, with lower treatment costs), this supports the adoption of the community-based care model, as recommended by the WHO.

Understanding demand for, and feasibility of, centre-based child-care for poor urban households: a mixed methods study in Dhaka, Bangladesh.

BACKGROUND: Centre-based child-care has potential to provide multiple health and development benefits to children, families and societies. With rapid urbanisation, increasing numbers of low-income women work with reduced support from extended family, leaving a child-care vacuum in many low- and middle-income countries. We aimed to understand perceptions of, and demand for, centre-based child-care in Dhaka, Bangladesh among poor, urban households, and test the feasibility of delivering sustainable centre-based child-care. METHODS: We used sequential mixed methods including a household survey (n = 222) and qualitative interviews with care-givers (n = 16), community leaders (n = 5) and policy-makers (n = 5). We co-produced and piloted a centre-based child-care model over ten-months, documenting implementation. A co-design focus group with mothers, parents' meetings, and qualitative interviews with child-care centre users (n = 5), non-users (n = 3), ex-users (n = 3) and staff (2) were used to refine the model and identify implementation issues. RESULTS: We found 24% (95% CI: 16,37%) of care-givers reported turning-down paid work due to lack of child-care and 84% (95% CI:74, 91%) reported wishing to use centre-based child-care and were willing to pay up to 283 Takka (~$3.30) per month. Adjusted odds of reported need for child-care among slum households were 3.8 times those of non-slum households (95% CI: 1.4, 10). Implementation highlighted that poor households needed free child-care with food provided, presenting feasibility challenges. Meta-inference across quantitative and qualitative findings identified the impact of the urban environment on child-care through long working hours, low social capital and fears for child safety. These influences interacted with religious and social norms resulting in caution in using centre-based child-care despite evident need. CONCLUSION: Sustainable provision of centre-based care that focuses on early childhood development requires subsidy and careful design sensitive to the working lives of poor families, particularly women and must respond to the dynamics of the urban environment and community values. We recommend increased research and policy focus on the evaluation and scale-up of quality centre-based child-care, emphasising early-childhood development, to support low-income working families in urban areas.

"Death is a better option than being treated like this": a prevalence survey and qualitative study of depression among multi-drug resistant tuberculosis in-patients.

BACKGROUND: Understanding of the relationship between multi-drug resistant tuberculosis and mental health is limited. With growing prevalence of multi-drug resistant tuberculosis, addressing mental ill-health has potential to improve treatment outcomes and well-being. In several low and middle-income contexts hospitalisation during treatment is common. Understanding of the impact on mental ill-health are required to inform interventions for patients with multi-drug resistant tuberculosis. Our aim was to identify the prevalence of comorbid depression among in-patients being treated for multi-drug resistant tuberculosis and to explore their experiences of comorbid disease and the care they received in a large specialist chest hospital in Dhaka, Bangladesh. METHODS: We conducted a quantitative cross-sectional survey among 150 multi-drug resistant tuberculosis in-patients (new cases = 34%, previously treated = 66%) in 2018. A psychiatrist assessed depression was assessed with the Structured Clinical Interview for Depression (SCID DSM-IV). We used multi-level modelling to identify associations with depression. Experience Bangladeshi researchers conducted qualitative interviews with 8 patients, 4 carers, 4 health professionals and reflective notes recorded. Qualitative data was analysed thematically. RESULTS: We found 33.8% (95% CI 26.7%; 41.7%) of patients were depressed. While more women were depressed 39.3% (95% CI 27.6%; 52.4%) than men 30.4% (95% CI 22%; 40.5%) this was not significant. After controlling for key variables only having one or more co-morbidity (adjusted odds ratio [AOR] = 2.88 [95% CI 1.13; 7.33]) and being a new rather than previously treated case (AOR = 2.33 [95% CI 1.06; 5.14]) were associated (positively) with depression. Qualitative data highlighted the isolation and despair felt by patients who described a service predominantly focused on providing medicines. Individual, familial, societal and health-care factors influenced resilience, nuanced by gender, socio-economic status and home location. CONCLUSIONS: Patients with multi-drug resistant tuberculosis are at high risk of depression, particularly those with co- and multi-morbidities. Screening for depression and psycho-social support should be integrated within routine TB services and provided throughout treatment.

Integrating a diabetes and hypertension case management package within primary health care: a mixed methods feasibility study in Bangladesh.

BACKGROUND: Almost three quarters of non-communicable disease (NCD) deaths, and 82% of premature NCD deaths, occur in low- and middle-income countries. Bangladesh has an estimated 7 million hypertensives and 10 million diabetics, and primary care is struggling to respond. Our aim was to develop and support implementation of a diabetes and hypertension case management package, and assess its appropriateness, feasibility and acceptability in two NCD clinics within two primary-care centres in Bangladesh. METHODS: We used a convergent mixed methods design. We first assessed the level of appropriate hypertension and cardiovascular disease patient management, based on a composite outcome indicator using data from patients' treatment cards. Appropriate management was primarily informed by International Diabetes Federation (IDF) and World Health Organisation (WHO) guidelines. We then performed qualitative in-depth interviews with doctors and patients to explain these quantitative findings and to understand the challenges to achieving appropriate patient management in the NCD clinics. RESULTS: Eighty-one newly diagnosed patients were recruited. Over 3 months, 53.1% (95% CI 42.3% to 63.6%) of patients were appropriately managed. We found incomplete diagnosis (especially missing hypertension diagnosis alongside diabetes) and non-provision of follow-up appointments were the main causes of the relatively low level of appropriate management. We conducted interviews with 11 patients and 8 health professionals and found a shortage of human resources, reporting materials, available drugs and diagnostic equipment. This undermined patients' willingness to attend clinics and doctors' willingness to offer follow-ups. Hands-on skill-building training was valuable in increasing doctors' competence for appropriate management, but was seen as a novel training method and faced constraints to implementation. CONCLUSIONS: A clinical guide, skill-based training and recording package can be implemented in routine primary care and can lead to appropriate management of around half of diabetic and hypertensive patients in a low-income country. However, considerable health systems challenges must be addressed before more patients can be managed appropriately.

Improving the quality of care of children in community clinics: an intervention and evaluation in Bangladesh.

SETTING: Community health care providers (CHCPs) in 40 rural community clinics of Comilla district, Bangladesh, were trained using a newly developed case-management job aid based on the World Health Organization Integrated Management of Childhood Illness and a communication guide. OBJECTIVES: To assess 1) the change in knowledge of the CHCPs after training; 2) the absolute quality of care provided by the CHCPs (determined as the proportion of children aged <5 years [under-fives] correctly diagnosed, treated and referred); and 3) the consultation behaviour of the CHCPs. DESIGN: Change in knowledge was assessed by tests pre-and post-training. The quality of care was determined by reassessments at the clinic exit by a medical officer, without a baseline comparison. Consultation behaviour was assessed through direct observation. The study was performed during 2014-2015. RESULTS: The mean standard knowledge score of the CH-CPs increased from 19 to 25 (P < 0.001). Of 1490 under-fives examined, 91% were correctly diagnosed, 86% were correctly treated and 99.5% received a correct referral decision. The CHCPs performed well on most of the measures of good communication, although one third did not explain the diagnosis and treatment to patients. CONCLUSION: The training was effective in changing knowledge. The CHCPs applied the knowledge gained and provided good quality care. Following these results, the Bangladesh Ministry of Health and Family Welfare has scaled up the training nationwide. The lessons learnt should be useful for other countries.

Contexte : Les prestataires des soins de santé communautaires (CHCP) de 40 communautés rurales du district de Comilla, au Bangladesh, ont été formés grâce à une aide au travail de prise en charge des cas, récemment élaborée, basée sur la « prise en charge intégrée des maladies de l'enfant ¼ de l'Organisation Mondiale de la Santé et sur un guide de communication.Objectifs : Evaluer l'amélioration des connaissances des CHCP après la formation ; la qualité absolue des soins prodigués par les CHCP (déterminée comme la proportion d'enfants âgés de <5 ans ayant eu un diagnostic, un traitement et une référence corrects) ; et le comportement des CHCP pendant la consultation.Schéma : L'amélioration des connaissances a été évaluée à l'aide de tests pré- et post-formation. La qualité des soins a été déterminée par des réévaluations lors de la sortie du centre par un officier médical, sans comparaison avec le statut de départ. Le comportement lors des consultations a été évalué par observation directe. L'étude a été réalisée en 2014­2015.Résultats : Le score moyen de connaissance des CHCP a augmenté de 19 à 25 (P < 0.001). Sur 1490 enfants âgés de <5 ans examinés, 91% ont eu un diagnostic correct, 86% un traitement correct et 99,5% ont bénéficié d'une décision de référence correcte. Les CHCP se sont bien comportés en ce qui concerne la plupart des mesures de bonne communication ; cependant, un tiers d'entre eux n'a pas expliqué le diagnostic et le traitement aux patients.Conclusion : La formation a été efficace en termes d'amélioration des connaissances. Les CHCP ont mis en application les connaissances acquises et ont fourni des soins de bonne qualité. Au vu de ces résultats, le Ministère de la Santé et du Bien-être Familial du Bangladesh a étendu la formation à tout le pays. Les leçons apprises devraient être utiles à d'autres pays.

Marco de referencia: Los agentes comunitarios de salud de 40 consultorios rurales del distrito de Comilla, en Bangladesh, recibieron capacitación con una ayuda de trabajo desarrollada recientemente sobre el manejo de los casos basado en el enfoque de 'la atención integrada de las enfermedades prevalentes de la infancia' de la Organización Mundial de la Salud y también una guía en materia de comunicación.Objetivos: Evaluar las modificaciones en los conocimientos de los agentes comunitarios de salud después de la capacitación; la calidad absoluta de la atención que prestaban (medida según la proporción de niños en edad <5 años que recibieron un diagnóstico, tratamiento y remisión correctos); y su comportamiento durante las consultas.Método: Las modificaciones en los conocimientos se analizaron mediante pruebas realizadas antes y después de la capacitación. Un médico de planta evaluó la calidad de la atención a la salida de la consulta, sin un punto de comparación. El comportamiento durante la consulta se evaluó mediante la observación directa. El estudio se llevó a cabo en el 2014 y el 2015.Resultados: La puntuación promedio de los agentes comunitarios de salud en la escala de conocimientos corrientes mejoró de 19 a 25 (P < 0,001). De los 1490 niños en edad <5 años examinados, el diagnóstico fue acertado en el 91%, el tratamiento fue apropiado en el 86% y 99,5% de los niños obtuvieron una remisión correcta. El desempeño de los agentes comunitarios en la mayoría de las medidas de comunicación fue adecuado, aunque un tercio de ellos no explicó el diagnóstico y el tratamiento a los pacientes.Conclusión: La capacitación modificó eficazmente los conocimientos de los agentes comunitarios de salud. Los agentes aplicaron los conocimientos adquiridos y prestaron una atención de buena calidad. Con base en estos resultados, el Ministerio de Salud y Bienestar Familiar de Bangladesh ha ampliado la escala de la capacitación a todo el país. Las enseñanzas extraídas en esta experiencia serán muy útiles en otros países.

Androgen receptor gene mutations are rarely associated with isolated penile hypospadias.

PURPOSE: Hypospadias has no known single etiology but it has been linked to androgen insensitivity caused by mutations of the androgen receptor gene. The purpose of this study was to search for such mutations in cases of various degrees of isolated hypospadias to determine whether such an association exists and, if so, with any particular anatomical subgroup. MATERIALS AND METHODS: Isolated deoxyribonucleic acid from the penile tissue of 40 patients undergoing reconstructive surgery was screened for mutations of the coding regions of the androgen receptor gene using single strand conformational polymorphism analysis. In cases with abnormal single strand conformational polymorphism findings sequence analysis of the deoxyribonucleic acid was performed to define the mutation. RESULTS: A missense mutation of exon 2 of the androgen receptor gene was noted in 1 patient with isolated distal penile shaft hypospadias. Sequence analysis revealed that the mutation changed amino acid residue 546 from proline to serine. No abnormalities were detected in the other 39 patients. CONCLUSIONS: Isolated distal shaft hypospadias is associated with mutations of the androgen receptor gene but these mutations appear to be a rare cause of hypospadias.