Non-communicable disease clinics in rural Ethiopia: why patients are lost to follow-up.

BACKGROUND: Providing medical care for non-communicable diseases (NCDs) in rural sub-Saharan Africa has proved to be difficult because of poor treatment adherence and frequent loss to follow-up (LTFU). The reasons for this are poorly understood. OBJECTIVE: To investigate LTFU among patients with two different but common NCDs who attended rural Ethiopian health centres. METHOD: The study was based in five health centres in southern Ethiopia with established NCD clinics run by nurses and health officers. Patients with epilepsy or hypertension who were lost to follow-up and non-LTFU comparison patients were identified and traced; a questionnaire was administered enquiring about the reasons for LTFU. RESULTS: Of the 147 LTFU patients successfully located, 62 had died, moved away or were attending other medical facilities. The remaining 85 patients were compared with 211 non-LFTU patients. The major factors associated with LTFU were distance from the clinic, associated costs and a preference for traditional treatments, together with a misunderstanding of the nature of NCD management. CONCLUSIONS: The delivery of affordable care closer to the patients' homes has the greatest potential to address the problem of LTFU. Also needed are increased levels of patient education and interaction with traditional healers to explain the nature of NCDs and the need for life-long management.

Insulin-requiring diabetes in Ethiopia: associations with poverty, early undernutrition and anthropometric disproportion.

BACKGROUND/OBJECTIVES: Most insulin-requiring diabetes patients in Ethiopia have an atypical form of the disease, which resembles previous descriptions of malnutrition-related diabetes. As so little is known about its aetiology, we have carried out a case-control study to evaluate its social and nutritional determinants. SUBJECTS/METHODS: Men and women with insulin-requiring diabetes (n=107), aged 18-40 years, were recruited in two centres, Gondar and Jimma, 750 km northwest and 330 km southwest of the capital, Addis Ababa, respectively. Controls of similar age and sex (n=110) were recruited from patients attending other hospital clinics. RESULTS: Diabetes was strongly associated with subsistence farming, odds ratio=3.5 (95% confidence interval: 1.5-7.8) and illiteracy/low levels of education, odds ratio=4.0 (2.0-8.0). Diabetes was also linked with a history of childhood malnutrition, odds ratio=5.5 (1.0-29.0) the mother's death during childhood, odds ratio=3.9 (1.0-14.8), and markers of poverty including poorer access to sanitation (P=0.004), clean water (P=0.009), greater overcrowding (P=0.04), increased distance from the clinic (P=0.01) and having fewer possessions (P=0.01). Compared with controls, people with diabetes had low mid upper arm circumference, body mass index (BMI) and fat/lean body mass (P<0.01). In addition, men with the disease tended to be shorter, were lighter (P=0.001), with reduced sitting height (P=0.015) and reduced biacromial (P=0.003) and bitrochanteric (P=0.008) diameters. CONCLUSIONS: Insulin-requiring diabetes in Ethiopia is strongly linked with poor education and markers of poverty. Men with the disease have associated disproportionate skeletal growth. These findings point towards a nutritional aetiology for this condition although the nature of the nutritional deficiency and its timing during growth and development remains obscure.

Insulin-requiring diabetes in rural Ethiopia: should we reopen the case for malnutrition-related diabetes?

AIMS/HYPOTHESIS: We evaluated the incidence of insulin-requiring diabetes in a rural area of sub-Saharan Africa. METHODS: Health surveillance data from a chronic disease programme in two zones of Ethiopia, Gondar and Jimma, were studied. The two zones have a population of more than 5,000,000 people. RESULTS: In Gondar Zone (1995-2008) and Jimma Zone (2002-2008) 2,280 patients presented with diabetes, of whom 1,029 (45%) required insulin for glycaemic control at diagnosis. The annual incidence of insulin-requiring diabetes was 2.1 (95% CI 2.0-2.2) per 100,000 and was twice as high in men (2.9 per 100,000) as in women (1.4 per 100,000). In both sexes incidence rates peaked at the age of 25 to 29 years. Incidence rates in the urban areas of Gondar and Jimma were five times higher than in the surrounding rural areas. Patients with insulin-requiring diabetes from rural and urban areas had a very low BMI and most were subsistence farmers or unemployed. CONCLUSIONS/INTERPRETATION: The typical patient with diabetes in rural Ethiopia is an impoverished, young adult male with severe symptoms requiring insulin for glycaemic control. The low incidence rates in rural compared with urban areas suggest that many cases of this disease remain undiagnosed. The disease phenotype encountered in this area of Africa is very different from the classical type 1 diabetes seen in the West and most closely resembles previous descriptions of malnutrition-related diabetes, a category not recognised in the current WHO Diabetes Classification. We believe that the case for this condition should be reopened.

Primary care treatment of epilepsy in rural Ethiopia: causes of default from follow-up.

BACKGROUND: In 1998, we set up nurse-led epilepsy clinics in five rural health centres around Gondar in northern Ethiopia. Despite good treatment outcomes, two years after registration only 40% of patients were still under follow-up. AIM: The purpose of this study was to examine the causes of default and factors that might improve adherence to follow-up. METHOD: The study was carried out at one of the five health centres. Patients who had defaulted from follow-up were identified from the clinic register. Trained enumerators visited the patients' villages and administered a questionnaire to the patients, or relatives if the patient was not available. RESULTS: 113 patients were traced. 28 (25%) had died and 21 (19%) had moved from the area. Of the remaining 64 patients, seven were accessing treatment from another source and 13 were in remission off treatment. 44 patients were still experiencing seizures and were on no treatment or had reverted to traditional remedies. The main reason given for default, in 44% of the patients, was difficulty in travelling to the health centre. 12% claimed that they preferred traditional remedies and 9% felt that they had not been improved by medical treatment. CONCLUSION: Despite decentralisation of care to rural health centres, the most common reason for default was the distance to travel to the health centre. Further decentralisation of care to a community level coupled with improved education may reduce default from follow-up.

Anaesthesia and hospital links: strengthening healthcare through South-North hospital partnerships.

Health services can respond to the needs of the poorest people in developing countries if those who work in the front line of health care are supported and motivated and if development needs in services and training programmes can be filled. This can be achieved when a Health Link between a southern hospital and/or training school and its northern counterpart is designed to build a disciplined and long-term programme of staff development including the needs of anaesthetic services, which meets the needs identified by the southern partner. Development of anaesthetic practice is best carried out in the context of an institution-wide Health Link where not only the staff and systems involved in anaesthesia but all the essential 'back office' or support services are also supported and developed.

The outcome of peripartum cardiac failure in Zaria, Nigeria.

We have studied 227 women who had peripartum cardiac failure (PPCF) in Zaria, Nigeria, since 1969-72. This follow-up and review of survivors in 1993-95 depended chiefly on a Zaria woman (A. Abdullahi) and on her careful reporting. Overall, 31 (13.7%) were completely lost to follow-up, 17 (7.5%) were thought to be alive, and there were data on 179 others (78.8%). Of the 75 known deaths, 55 were cardiovascular--20 due to PPCF, 31 due to cardiac failure unrelated to pregnancy (CF), and four were due to a cerebrovascular accident. PPCF recurred in 13% of 551 subsequent pregnancies. Thirty-two women had a recurrence of PPCF only, and 27 an episode of CF only. Blood pressures rose steadily over the years. An enlarged left ventricle on discharge after the index admission predicted a poor prognosis. In 1993-5, we compared 100 survivors with 100 non-PPCF controls: 96 PPCF women but only 50 control women took extra salt (p = 0.0001). Significantly more PPCF women than controls had a diastolic pressure of 110 mm Hg (p = 0.011). The syndrome is probably provoked in potentially hypertensive women by the traditional practices of eating kanwa, which is rich in Na+, taking additional excess salt and heating the body after delivery. Evidence is presented that PPCF women are potentially hypertensive, and cannot handle the excess ingested sodium which therefore leads to hypervolaemia and thus PPCF.

Doctors' continuing education in Tanzania: distance learning.

A distance learning programme for medical officers and their assistants at the district level has produced some valuable lessons for future activities in continuing education. Besides correspondence and study materials, face-to-face contact between students and their tutors is a particularly important ingredient, as it provides the guidance, flexibility and motivation that are essential for an effective programme.

Appropriate training for maternal health and the attributes of the trainer.

This review describes the qualities which those who are trainers in safe motherhood and other programs should display. The educational principles and objectives for maternal health workers, based on the tasks which they have to do and expressed in the skills and competences they must attain, are related to practical methods of training. Problem-based learning is advocated and the value of distance education for rural workers is discussed.

Atrial natriuretic peptide, aldosterone, and plasma renin activity in peripartum heart failure.

Plasma concentrations of atrial natriuretic peptide and aldosterone and plasma renin activity were measured in patients with peripartum heart failure and in age matched healthy women post partum. Both groups had carried out traditional postpartum practices of salt consumption and body heating. Plasma concentrations (mean (SEM)) of atrial natriuretic peptide were significantly higher in the seven patients with peripartum heart failure (146.9 (24.3) pg/ml) than in the seven controls (4.4 (0.8) pg/ml). Both plasma aldosterone and plasma renin activity were suppressed in the patients with peripartum heart failure. After treatment for the heart failure plasma atrial natriuretic peptide fell considerably and there were associated increases in plasma aldosterone and plasma renin activity. The high plasma concentrations of atrial natriuretic peptide may have been a compensatory response to salt and water retention as well as to the heart failure. These high concentrations could also, in part, have suppressed the release of aldosterone and renin in an attempt to correct for volume overload.

Peripartum cardiac failure. A ten year follow-up study.

A cohort of patients with peripartum cardiac failure (PPCF) was followed for 10 years after the initial illness. The follow up rate was 78%. Fifty two per cent of patients improved without further episodes of heart failure. PPCF recurred in 26 per cent. Heart failure unrelated to pregnancy was seen in 13%, and 9% of the patients progressed to dilated cardiomyopathy. Transient hypertension was seen in 87% of patients on admission, and later hypertension was found in 45%. Late hypertension influenced heart size more when recurrent PPCF or progressive heart failure was present. Anaemia on admission had no effect on subsequent heart size. The electrocardiogram may continue to be abnormal for up to 10 years in normotensive patients who had no heart failure. The abnormal electrocardiogram in patients with persistent cardiomegaly may represent progressive myocardial damage. Mortality rate was highest (11%) in the first year and declined thereafter. Cardiac deaths were common in patients with recurrent PPCF or progressive heart failure.

Medical education's role in primary care/community health: a model from Kumasi, Ghana.

Providing primary care for the medically underserved is an international problem. In the developing world the problem is accentuated by the disparity between resources and needs. Although during the past few decades much has been accomplished worldwide to improve primary care, medical educators have not adequately responded to the challenge of preparing students to participate in community health services, education, and research. This paper describes a medical school program from the Department of Community Health, School of Medical Sciences, Ghana. It is a program designed to prepare medical students for primary care by making community health a curriculum component of all three years of medical education. The program has potential for replication in the industrial as well as the developing world.