Costing total hip arthroplasty in a South African state tertiary hospital.

BACKGROUND: Most South Africans depend on the public sector for health services. There is an increasing demand for arthroplasty in the public sector, but a paucity of academic data regarding its cost. OBJECTIVES: To: (i) identify the factors that determine the cost of an uncomplicated primary hip arthroplasty; and (ii) make recommendations on cost optimisation. METHODS: This was a cross-sectional study. Patients who met the inclusion criteria had their hospital financial records reviewed from October 2015 to March 2017. Six cost centres were utilised: inpatient admission, theatre and anaesthesia, ambulatory, prosthesis, physiotherapy and blood bank. The data were statistically analysed. RESULTS: Fifty-five patients met the study inclusion criteria. Data were stratified into categories. Analysis of variance (ANOVA) was used to test the data, and significant differences were found in the prosthesis, inpatient admission and ambulatory cost centres at a 95% significance level. The least significant difference was used to test the ANOVA results that paired significant categories. No cost centre showed significance over the other categories. Data for the six cost centres were compared with the current literature and industry best practice. Eight recommendations are made. CONCLUSIONS: The study showed that clinicians need to be aware of procedural costing in the current financial climate. There are still opportunities to optimise cost containment in the state sector.

Mental health and caregiving experiences of family carers supporting people with psychosis.

AIMS: Family carers supporting an individual with psychosis often experience poorer mental health, however, little is known about specific risk factors among these carers. We investigated the associations between demographic, caregiving characteristics and mental health outcomes in family carers supporting an individual with psychosis and compared carers' outcomes with general population norms. METHODS: We analysed baseline data from the COPe-support randomised controlled trial of online psychoeducation and peer support for adult carers supporting an individual with psychosis between 2018 and 2020. We collected carers' demographic and health outcome data, including wellbeing using Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS as primary outcome), quality of life using EQ-5D-5L and caregiving experience assessed with Experience of Caregiving Inventory. We tested associations between carers' demographic and caregiving characteristics for each outcome in turn and meta-analysed carers' WEMWBS and EQ-5D-5L with Health Survey England (HSE) general population data from 2016 and 2017, respectively. RESULTS: The 407 carers of people with psychosis had a mean WEMWBS score of 42.2 (s.d. 9.21) and their overall weighted pooled WEMWBS score was 7.3 (95% confidence interval (CI) -8.6 to -6.0, p < 0.01) lower than the HSE general population sample, indicating carers have poorer mental wellbeing by more than double the minimum clinically important difference of 3 points on WEMWBS. Among all caring relationships, partners had poorer wellbeing compared to parents with lower WEMWBS score (-6.8, -16.9 to 3.3, p = 0.03). Single carers had significantly poorer wellbeing (-3.6, -5.6 to -1.5, p < 0.01) and a more negative caregiving experience than those who were cohabiting. Spending more than 35 h per week caregiving increased carers' negative experience significantly (p = 0.01). CONCLUSION: Carers of people with psychosis have poorer mental health than non-carers. Partners, lone carers and those spending more than 35 h per week on caring were found to be most at risk of poor mental health. Based on the results, we advocate that the details of carers for individuals with psychosis should be added to the existing carers or severe mental illness registers at all general practitioner surgeries and for their wellbeing screened routinely. Future large-scale prospective studies are needed to develop a predictive model to determine risk factors, hence to aid early identification of carers' support needs. Such understandings are also useful to inform tailored intervention development.

Cost effectiveness of facility and home based HIV voluntary counseling and testing strategies in rural Uganda.

BACKGROUND: In Uganda, the main stay for provision of human immunodeficiency virus (HIV) voluntary counseling and testing (VCT) has been at health facilities. Home based VCT on the other hand, was initiated in the country to improve service coverage. OBJECTIVE: To evaluate the cost effectiveness of facility- and home-based HIV VCT strategies in rural southwestern Uganda. METHODS: Data on costs and effectiveness of facility- and home-based HIV VCT intervention strategies was collected in two sub-Counties in rural southwestern Uganda. Costing was performed using the ingredients approach. Effectiveness was measured as the number of HIV sero-positive clients identified. Incremental Cost-Effectiveness Ratios (ICERs) were calculated from the provider perspective. RESULTS: The cost per client tested were US$6.4 for facility based VCT and US$5.0 for home based VCT. The corresponding costs per positive case identified were US$86.5 and US$54.7 respectively. The incremental cost to providers per additional positive case identified by facility based VCT was US$3.5. CONCLUSION: Home based VCT was the least costly strategy per client tested and was also cost effective in identifying HIV sero-positive clients in rural areas. This strategy should therefore be promoted to improve service coverage and thereby facilitate early and extensive detection of clients eligible for treatment.

Socio-economic effects of khat chewing in north eastern Kenya.

BACKGROUND: The khat habit is a widespread phenomenon which has in the past two decades spread to parts of Western Europe and North America from Eastern Africa and the Arabian Peninsula. Although khat has been identified as one of the most commonly abused substances in Kenya, restrictions on cultivation, trade and usage have been non-existent since its legalisation in 1977. OBJECTIVE: To describe the socio-economic effects of khat chewing in Ijara District in the North Eastern Province of Kenya. DESIGN: Cross sectional study. SETTING: Ijara District, North Eastern Kenya. SUBJECTS: Fifty respondents were interviewed. RESULTS: Eighty eight percent of the respondents were khat chewers, and the majority (80%) had family members who engaged in the khat habit. There was a general lack of education on the negative effects of khat chewing. Due to reported mood changes and withdrawal symptoms when not chewing khat, many respondents used more than half of their domestic budgets on khat, but few (28%) perceived this as a waste of resources. Fifty four percent of khat chewers typically started the habit during the day, implying a waste of time for productive work. However, only 40% of the persons interviewed admitted that the drug affected work performance negatively. The khat habit was associated with strain on family relationships, anti-social behaviour and health effects such as insomnia. CONCLUSION: In spite of the negative socio-economic impact of khat in Ijara District, khat consumption remains a widespread habit.

Experiences against HIV/AIDS/STDS of Somalis in exile in Gothenburg, Sweden.

Since 1989, the City of Göteborg Immigrant Services Administration has been making efforts to inform about HIV/AIDS. The purpose has been to ensure that even immigrant residents of the City of Göteborg (Gothenburg) have access to relevant information about HIV/AIDS. The administration's efforts have been a part of the collected efforts of Gothenburg to prevent the spreading of HIV. This paper attempts to discover and describe experiences against HIV/AIDS/STDs of Somalis in Exile in Gothenburg, Sweden. A qualitative sociological in-depth interviews with 13 individuals (6 women and 7 men) and with semi-structured and themetized emerging design was carried on. A follow up focus group interviews with 10 individuals (2 women and 8 men) was also performed. The paper reveals that the general understanding of subjects on the issues under discussion is almost the same though details may vary from one research participant to the other. They have described this through narratives. STDs and specially HIV/AIDS was perceived as something dishonourable by the subjects. The HIV/AIDS is perceived as a sin which Allah sends to punish those who have fornication or sex without marriage (Zinna). Of course, this tendency of shying off the problem leads to ignorance of how to behave, which in turn decreases the risk of perceptions and as a result may also increase the risk of being infected. As concerns protection as a preventive measure, attitudes vary. The traditionalists have argued that condom increased the possibility of promiscuity or fonication, while young and more modern people saw condom as something good. We may conclude that Somalis who have arrived in Western world and in Sweden as adults did never have a modern sexual education for themselves due to socio-cultural reasons and this has important implication for giving proper information to their children about sex organs, human sexual development and preventive measures against HIV/AIDS/STDs. These immigrant parents should be offered culturally sensitive communication and educational programmes aimed at raising their awareness about teenagers sexuality and the preventive measures against HIV/AIDS/STDs.

Gendered experiences of conflict and co-operation in heterosexual relations of Somalis in exile in Gothenburg, Sweden.

Political upheaval and poverty at home has been forcing many Somalis to immigrate. These immigrants do not only leave their physical house, families, relatives, loved ones, friends, but also familiarities, culture, customs, and often they do end up in no man's land being between their own and new home culture. Available reports suggest that there are about 15,000 Somalis in Sweden and their majority came here from late 1989 to 1996. About one third these immigrants live in and around the city of Gothenburg. This paper explores and describes gendered experiences of conflict and co-operation in heterosexual relations of Somalis in exile in Gothenburg, Sweden. A qualitative sociological in-depth interviews with 6 women and 7 men was performed during May 1999 to January 2000. A follow up focus group interviews with 10 people (2 women and 8 men) was also carried on. The results show that both the Somali culture and Muslim religion do not support the children being taught sex education in schools or the names of the sex organs being pronounced other than to be used as metaphors. The girls, unlike their age group males, experience a very painful and terrifying process during childhood in which their self-esteem is downgraded by means of serious degrading traditional active violence such as female genital mutilation and visible virginity control. The narratives tell stories in which Somali women are degraded and expected to obey in situations characterised by their man's arbitrariness. They are subject to a very extensive form of social control, which is especially pronounced on issues regarding sexuality. Their integrity as women is, consequently set aside. When Somali refugees came to Sweden some of them came to adopt much of the modern lifestyle and cultural norm systems, preferable young people and some of the females. Relating to a new culture with its new expectations on the norm obedience also created changes in self-esteem. Exile situation tends to generate horizontal conflicts, among spouses and between groups of people. It also tends to generate vertical conflicts because now generations stand up against each other and this is especially pronounced when it is about issues of sexuality and sexual relations. The young generations questions their parents authority. They are now living in new social context and perceive risks, as well as possibilities. Their new dreams and choices, however, do not fit their parents' expectations, which sometimes leads to big problems. From a traditional perspective these deviants lack of respect for traditions and the original culture. From a male perspective this means more specifically a lack of respect for male dominance and superiority.

Continuous countercurrent extraction of hemicellulose from pretreated wood residues.

Two-stage dilute acid pretreatment followed by enzymatic cellulose hydrolysis is an effective method for obtaining high sugar yields from wood residues such as softwood forest thinnings. In the first-stage hydrolysis step, most of the hemicellulose is solubilized using relatively mild conditions. The soluble hemicellulosic sugars are recovered from the hydrolysate slurry by washing with water. The washed solids are then subjected to more severe hydrolysis conditions to hydrolyze approx 50% of the cellulose to glucose. The remaining cellulose can further be hydrolyzed with cellulase enzyme. Our process simulation indicates that the amount of water used in the hemicellulose recovery step has a significant impact on the cost of ethanol production. It is important to keep water usage as low as possible while maintaining relatively high recovery of soluble sugars. To achieve this objective, a prototype pilot-scale continuous countercurrent screw extractor was evaluated for the recovery of hemicellulose from pretreated forest thinnings. Using the 274-cm (9-ft) long extractor, solubles recoveries of 98, 91, and 77% were obtained with liquid-to-insoluble solids (L/IS) ratios of 5.6, 3.4, and 2.1, respectively. An empirical equation was developed to predict the performance of the screw extractor. This equation predicts that soluble sugar recovery above 95% can be obtained with an L/IS ratio as low as 3.0.

Softwood forest thinnings as a biomass source for ethanol production: a feasibility study for California.

A plan has been put forth to strategically thin northern California forests to reduce fire danger and improve forest health. The resulting biomass residue, instead of being open burned, can be converted into ethanol that can be used as a fuel oxygenate or an octane enhancer. Economic potential for a biomass-to-ethanol facility using this softwood biomass was evaluated for two cases: stand-alone and co-located. The co-located case refers to a specific site with an existing biomass power facility near Martell, California. A two-stage dilute acid hydrolysis process is used for the production of ethanol from softwoods, and the residual lignin is used to generate steam and electricity. For a plant processing 800 dry tonnes per day of feedstock, the co-located case is an economically attractive concept. Total estimated capital investment is approximately $70 million for the co-located plant, and the resulting internal rate of return (IRR) is about 24% using 25% equity financing. A sensitivity analysis showed that ethanol selling price and fixed capital investment have a substantial effect on the IRR. It can be concluded that such a biomass-to-ethanol plant seems to be an appealing proposition for California, if ethanol replaces methyl tert-butyl ether, which is slated for a phaseout.

Somalis giving birth in Sweden: a challenge to culture and gender specific values and behaviours.

OBJECTIVES: Giving birth in a foreign country implies going through a life event with little or no access to your own traditions and social support. The aim of this study was to study the childbirth experiences of Somali women and men in Sweden. DESIGN: Qualitative. Nine women and seven men were interviewed. Data collection was characterised by an openness to new ideas during the interview and the interviews were analysed according to the grounded theory technique. FINDINGS: The meeting of Somalis with Swedish antenatal and delivery care was a multicultural event. It revealed social, medical, cultural and gender factors advocating space in the arena of childbirth. The Somalis constituted a homogeneous group with regard to their cultural belonging and motives for exile. The subjects were heterogeneous in that they represented a great variety in social and demographic background as well as in experiences, feelings and modes of expression. One striking finding was the Somali man's dramatic entrance into childbirth, which seemed to have a strong impact on the Somali woman's well-being during delivery. The study showed difficulties in getting used to the Swedish model of parenthood and in finding new role divisions in the couple relationship. Some of the subjects had experienced a strengthening of their marriage and an increased understanding of each other. Others commented that various aspects of traditional womanhood and manhood were lost as a result of the unfamiliar gender structures in Sweden. CONCLUSION: The Somalis' experiences of childbirth in Sweden can be understood by using the theoretical concept of gender, rather than culture. Our own and other studies show that women and men may have different frames of reference in childbirth, where the women mainly focus on biological circumstances and the men on the social and cultural aspects of birth. The Somali couple were found to be vulnerably positioned, with the professionals having the important role of supporting and empowering Somali parents.

Excess female mortality in rural Somalia--is inequality in the household a risk factor?

Gender differences in mortality risks in rural Somali communities were studied to assess their relation to literacy, marital status and family economy between January 1987 and December 1989. In all, 6947 person-years form the basis for the demographic analysis and estimations of mortality rates and survival. Both sexes showed similar mortality risks in infancy and early childhood, but females demonstrated a greater risk of dying during their reproductive life than males. Respiratory symptoms, diarrhoea, fever and jaundice dominated the symptoms prior to death Illiteracy in women considerably increased the risk of dying from 15 years and onwards particularly when living with literate men. The life expectancy from 15 years was 58 for a literate male but only 42 years for an illiterate woman living with a literate head of household. Multivariate analyses showed after adjustment for marital status and literacy that an excess female mortality from 15 years, but especially from 45 years, was associated to a household situation, where the woman did not subside on farming but on other, mainly commercial, activities. This vulnerability of females was associated to the recession of the economy in the pre-war situation in Somalia, a backlash hitting women trying to earn their living. To conclude, gender differences in a number of factors in the household-literacy, marital status and especially source of income-were disadvantageous for the women, increasing the mortality risk in this setting.

Use of participatory rural appraisal (PRA) tools for investigating tick ecology and tick-borne disease in Somaliland.

This paper describes the use of the participatory rural appraisal tools matrix scoring and seasonal calendars to collect data on tick ecology and tick-associated health problems of livestock in Sanaag region of Somaliland. The potential application of these techniques is discussed.

Diarrhoea among children in rural Somalia. Maternal perceptions, management and mortality.

Diarrhoea was the second most common symptom of disease in a longitudinal study of 431 children under 5 years of age in rural Somalia. Most mothers perceived diarrhoea as a condition in which oral rehydration therapy (ORT) and feeding were logical parts of its management. During 1 year of observation, ORT was used in the household in one-third of the episodes of diarrhoea, mostly by non-farming, young and literate mothers. Infants were treated more often than older children, as were also children in smaller households. In a 3-year demographic surveillance in the same area (1219 person years), the under-5 mortality from diarrhoea in children of literature and illiterate mothers was 43 per 1000 (95% CI 0-84) and 93 per 1000 (95% CI 60-101), respectively. The findings suggest that the use of ORT is associated with a mother's ability to allocate time to health care and her general position in the household.

PIP: Diarrheal disease is a major cause of morbidity and mortality in Somali children. The use of oral rehydration therapy (ORT) in the household management of diarrhea was therefore strongly advocated in the 1989-91 national health plan. The mother is the major provider of health care in the home, particularly for children. This paper reports findings from a study conducted to determine maternal perceptions about and management of diarrhea in childhood at home, to analyze possible determinants of the use of ORT, and to assess its impact upon mortality from diarrhea. In this study, ORT had been promoted for use in the home by health services in two rural villages situated between the two Somali rivers. A cohort of 431 under-5 year old children was followed for one year to assess their morbidity and how health problems were managed in the home. A 3-year demographic survey in the same area allowed the estimation of overall under-5 mortality and diarrhea-associated under-5 mortality. Interviews were conducted with 220 women to learn of their perceptions about diarrhea in childhood and its treatment. Diarrhea was the second most common symptom of disease in this longitudinal study, with most mothers perceiving diarrhea as a condition in which ORT and feeding were logical approaches to its management. During the one-year observational period, ORT was used in the household in one third of diarrheal episodes, mostly by non-farming, young, and literate mothers. Infants were treated more often than older children, as were also children in smaller households. In the three-year demographic surveillance, under-5 mortality from diarrhea in children of literate and illiterate mothers was 43 per 1000 and 93 per 1000, respectively. These findings suggest that the use of ORT is associated with a mother's ability to allocate time to health care and her general position in the household.

The growth chart--a road to health chart? Maternal comprehension of the growth chart in two Somali villages.

Growth monitoring is so far not implemented on a large scale in the Somali health services. Available reports indicate that growth faltering is common. However, the use of growth charts as a tool for health education has been questioned. This study examines the ability of 199, predominantly illiterate, rural Somali mothers to understand the growth chart message after an intensive period of growth chart use and education. During a home-based interview the mothers were asked to combine a set of four growth curves with a set of four pictures, showing the corresponding developments of four children. The mothers managed significantly better to interpret the charts than could be expected by chance alone. Maternal age, number of children and literacy did not differ much between those who correctly and incorrectly combined pictures and charts. Almost all mothers recognised the value of the growth chart as being good for the control and promotion of their children's health and/or growth. We conclude that the growth chart may be an applicable and appropriate tool even with illiterate mothers, provided that other prerequisites for successful growth monitoring, e.g. appropriate health services, are available.

Camel trypanosomiasis and its vectors in Somalia.

Blood samples from 3000 Somali camels (Camelus dromedarius) were examined for trypanosome infection. Of these, 160 (5.33%) were infected with Trypanosoma evansi, one (0.03%) with T. congolense and one (0.03%) with T. brucei. Camel trypanosomiasis occurred in most areas of tabanid infestation throughout the country. The tabanids Philoliche zonata and P. magretti are incriminated as the major vectors of the disease.

Epidemiology of hepatitis B in Somalia: inference from a cross-sectional survey of serological markers.

Hepatitis B markers were determined by radioimmunoassay in 383 adults from different areas of Somalia and in 135 pregnant females and 428 children from Mogadishu. The highest incidence of HBsAg among adults was among nomadic males (20/85; 23%). The frequencies were lower in males from the agricultural and coastal area, i.e. 16/93 (17%) and 14/98 (14%) respectively. The lowest frequency of HBsAg was among women from the coastal area (6/72; 8%). Among the pregnant women 14 were positive for HBsAg, none of whom had HBeAg. Low levels of positivity for HBsAg were found both among children under 4 years and among those between 4 and 13 years of age - 3/94 (3%) and 5/128 (4%) respectively. In the age group 15-19 years, 50% showed seroconversion from HBeAg to anti-HBe. 7 out of 41 HBsAg carriers of ages over 20 had HBeAg. Early seroconversion from HBeAg to anti-HBe and a low level of HBsAg positivity in children indicate that vertical transmission is not important in Somalia. The low frequency of HBsAg in Mogadishu children may have one of the following explanations: (i) the infection occurs during adolescence, (ii) Mogadishu is a low-prevalence area and the examined adults were not born in Mogadishu, or (iii) a change in hepatitis B epidemiology has taken place in the area during the last 2 decades and the relatively higher prevalence of HBsAg in adults might reflect higher rates of infection in their childhood.