Establishment of a urology service in a developing country: an observational study of outcomes in transurethral prostate resection procedures in Vanuatu.

BACKGROUND: The Royal Australasian College of Surgeons (RACS) via the Pacific Island Program (PIP) administer yearly urology visits to Vanuatu to perform surgery and deliver training in the management of urological conditions. In conjunction with the Vanuatu Ministry of Health a self-sufficient urology service has developed, specifically performing transurethral resection of the prostate (TURP) procedures. We review the TURP outcomes for the PIP and detail the development and outcomes of the first independent TURP service in the Pacific. METHODS: With retrospective local and RACS medical records, an observational study was performed of TURP procedures undertaken in Port Vila Central Hospital, Vanuatu over 6 years. Outcome measures comprised significant morbidity, prolonged post-operative admission, blood transfusion, TUR syndrome, successful trial of void, postoperative urinary incontinence, and perioperative mortality. Comparisons were made with univariate analysis between the RACS, local team, and international standardised values, with t-tests for continuous variables, and with Fisher's exact test for binary variables. FINDINGS: Since 2009, a total of 117 TURP procedures were performed. 84 by the PIP team and following training both in Vanuatu and Australia; the local team independently performed 33 TURPs. Comparisons of all outcomes measured between the local and PIP teams showed no statistically significant differences (appendix). 29 patients overall (22 in the PIP group and seven in the local group) required blood transfusions, eight (seven and one) failed their trial of void, 10 (seven and three) had a prolonged post-operative admission (>7 days); two patients died in the post-operative period both in the PIP group). 10 (seven and three) had postoperative urinary incontinence. There was no difference between mean length of stay (4·07 days vs 4·7 days; p=0·2081) and haemaglobin loss with no cases of TUR syndrome. Only the rate of transfusion was statistically significantly higher in the Vanuatu cohorts when compared with international standards (appendix). INTERPRETATION: The development of a local urological service and in particular a TURP service is a first for a Pacific Island Nation. Baseline data were obtained with encouraging outcomes reflecting careful patient selection, cautious management, and expertise accumulation. Planned prospective audit should overcome some of the difficulties encountered in performing a longitudinal study in a developing nation with suboptimum follow-up and challenging medical records. Through linkage between the PIP and the Vanuatu Ministry of Health capacity building an independent service provision can be achieved. This model could be replicated to establish a sustainable and self-sufficient surgical service in a developing country. FUNDING: None.

The sustainable farm families project: changing attitudes to health.

INTRODUCTION: Farm health and safety has historically focussed on strategies such as injury prevention, safety audits and fulfilling legislative responsibilities. However, farmer injuries mask deeper health issues including higher rates of cancer, suicides, cardiovascular disease and stress. The relationship between occupational health and safety and farm family health has not been fully investigated. The Sustainable Farm Families (SFF) project attempts to make this connection in order to address premature death, morbidity and injury on Australian farms. The SFF project illustrates how increasing health literacy through education and physical assessment can lead to improved health and knowledge outcomes for farm families. METHODS: The SFF project focuses on the human resource in the triple bottom line and is working with farmers, families, industry and universities to collaboratively assess and promote improvement in the health and wellbeing of farm families. Based on a model of extension that engages farm families as active learners where they commit to healthy living and safe working practices, the SFF project is proving to be an effective model for engaging communities in learning and change. Health education and information is delivered to farm men and women aged 18 to 75 years using a workshop format. Pre- and post-knowledge surveys, annual physical assessments and focus group discussions form the methodological context for the research over a three-year intervention. RESULTS: This article discusses the progress of the research outlining the design of the SFF project, the delivery and extension processes used to engage 321 farm families from within a broadacre and dairy-farming family sample. The article presents key learnings on intersectoral collaboration, engaging farmers and families in health, and the future for this project extending into agricultural industries across the nation. Key results reveal that health issues do exist in farming families and are often underreported by family members. Health indicators were at a level where referral and intervention was required in over 60% of men and 70% of women in bothbroad acre and dairy industries. Farm men and women verbalised health concerns relating to access, support and control mechanisms of the health system. Participants also revealed how they put into practice their new knowledge and how this has influenced their health. CONCLUSIONS: The key learning is that farm men and women who are at high risk of premature morbidity and mortality will participate in health education and assessment programs based on industry collaboration with high levels of individual participation. This program provides evidence that farmers will engage with health professionals if programs are presented to them in personally engaging and relevant ways. The SFF program is a definite tool for interventional health promotion that supports attitudinal change to health and farming practices.

Intervening to improve health indicators among Australian farm families.

The Sustainable Farm Families project (http://www.sustainablefarmfamilies.org.au/) was a 3-year demonstration and education project designed to influence farmer behavior with respect to family health and well-being among cropping and grazing farmers in Victoria, New South Wales, and South Australia, Australia. The project was conducted by the Western District Health Service, Hamilton, Australia, in partnership with farmers; Farm Management 500 (peer discussion group); the Victorian Farmers Federation; Royal Melbourne Institute of Technology; and Land Connect. During the 3 years of the project, 128 farmers-men (70) and women (58)-were enrolled. The project utilized a combination of small group workshops, individualized health action plans, and health education opportunities to encourage farm safety and health behavior changes and to elicit sustained improvements in the following health indicators: body mass index (BMI), total cholesterol, fasting blood glucose, and blood pressure. Mean changes in these health indicators were analyzed using repeated measures analysis of variance (ANOVA) and McNemar's test compared the proportion of individuals with elevated indicators. Among participants with elevated values at baseline, the following average reductions were observed: BMI 0.44 kg/m(2) (p = .0034), total cholesterol 48.7 mg/dl (p < .0001), blood glucose 10.1 mg/dl (p = .0016), systolic blood pressure 12.5 mm Hg (p < .0001), and diastolic blood pressure 5.0 mm Hg (p = .0007). The proportion of participants with elevated total cholesterol at baseline decreased after 24 months (p < .001). Such findings suggest that proactive intervention by farmer associations, rural health services, and government agencies may be an effective vehicle for promoting voluntary farm safety and health behavior change while empowering farm families to achieve measurable reductions in important health risk factors.