Human Resources for Health 2003 1: 10 (published 5 November 2003)
Identifying factors for job motivation of rural health workers in North Viet Nam
Marjolein Dieleman, Pham Viet Cuong, Le Vu Anh and Tim Martineau
In Viet Nam, most of the public health staff (84%) currently works in rural areas, where 80% of the people live. To provide good quality health care services, it is important to develop strategies influencing staff motivation for better performance.
An exploratory qualitative research was carried out among health workers in two provinces in North Viet Nam so as to identify entry points for developing strategies that improve staff performance in rural areas. The study aimed to determine the major motivating factors and it is the first in Viet Nam that looks at health workers' job perception and motivation. Apart from health workers, managers at national and at provincial level were interviewed as well as some community representatives.
The study showed that motivation is influenced by both financial and non-financial incentives. The main motivating factors for health workers were appreciation by managers, colleagues and the community, a stable job and income and training. The main discouraging factors were related to low salaries and difficult working conditions.
Activities associated with appreciation such as performance management are currently not optimally implemented, as health workers perceive supervision as control, selection for training as unclear and unequal, and performance appraisal as not useful. The kind of non-financial incentives identified should be taken into consideration when developing HRM strategies. Areas for further studies are identified.
BMC Complementary and Alternative Medicine 2003, 3: 8 (published 18 November 2003)
Complementary and alternative medicine (CAM) use by african american (AA) and caucasian american (CA) older adults in a rural setting: a descriptive, comparative study
Norma Cuellar1, Teresa Aycock2, Bridgett Cahill3 and Julie Ford4
1School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
2Regency Hospital, Meridian, MS, USA
3Emergency Department, South Central Regional Medical Center, Laurel, MS, USA
4Hattiesburg VA Clinic, Hattiesburg, MS, USA
The use of CAM is at an all time high. There is very little research that compares the use of CAM in elders by ethnicity in rural settings. The purpose of the study was to determine if there was a difference between African American and Caucasian American rural elders on use of CAM and self-reported satisfaction with CAM.
The design was a descriptive, comparative study of 183 elders who reported the number of CAM used and satisfaction with CAM. A convenience sample was recruited through community service organizations in the state of Mississippi. The availability of elders through the support groups, sampling bias, subject effect, and self-report were limitations of the study.
The commonest examples of CAM used by rural elders were prayer, vitamins, exercise, meditation, herbs, chiropractic medicine, glucosamine, and music therapy. Significant findings on SES and marital status were calculated. Differences on ethnicity and demographic variables were significant for age, education, and the use of glucosamine.
Health care providers must be aware that elders are using CAM and are satisfied with their use. Identifying different uses of CAM by ethnicity is important for health care practitioners, impacting how health care is provided.
Malaria Journal 2003, 2: 40
Sleeping arrangements and mosquito net use among under-fives: results from the Uganda Demographic and Health Survey
Frederick Mugisha1 and Jacqueline Arinaitwe2
1African Population and Health Research Center (APHRC), Kenya Shelter Afrique Center, Longonot Road, Upper Hill, P.O Box, 10787 - 00100, GPO Nairobi, Kenya
2CARE International in Uganda, Kampala, Uganda
The Roll Back Malaria Initiative has identified the under-fives as one of the high risk groups for malaria, and one of the strategies to fight malaria in this group is increasing mosquito net use. This implies that there must be selective targeting at the household level such that the children are protected. However, the Roll Back Malaria preferences must be reconciled with those at the household level to take into account household level preferences.
This paper is based on the 2000-2001 Uganda Demographic and Health Survey data in which information on mosquito net ownership and use was collected. The patterns of household mosquito net ownership and use for children under five years of age were examined using both bi-variate and multivariate analysis.
The preferences at the household level seem to be different; children use mosquito nets primarily because they happen to share a bed with their parents. A child who shares a bed with the mother is 21 times more likely to use a mosquito net than his/her counterpart.
Increasing mosquito net coverage such that 60% (the target for the RBM) of households have at least one mosquito net will not necessarily protect the under-fives. Either the coverage will have to be expanded or appropriate targeting strategies designed.
Cost Effectiveness and Resource Allocation 2004, 2: 1 (published 8 January 2004)
Cost-effectiveness as a main guiding principle in priority setting in resource poor settings: The case of Uganda
Lydia Kapiriri, Trude Arnesen and Ole F Norheim
Several studies carried out to establish the relative preference of cost-effectiveness of intervention and severity of disease as criteria for priority setting in health have shown a strong preference for severity of disease. These preferences may differ in contexts of resource scarcity, as in developing countries, yet information is limited on such preferences in this context.
This study was carried out to identify the key players in priority setting in health and explore their relative preference regarding cost-effectiveness of interventions and severity of disease as criteria for setting priorities in Uganda.
610 self-administered questionnaires were sent to respondents at national, district, health sub-district and facility levels. Respondents included mainly health workers. We used three different simulations, assuming same patient characteristics and same treatment outcome but with varying either severity of disease or cost-effectiveness of treatment, to explore respondents' preferences regarding cost-effectiveness and severity.
The response rate was 67.7%. Main actors in health were identified to be health workers, donors and politicians although respondents showed interest in more public and patient involvement.In priority setting, most of the respondents strongly supported consideration of both severity of disease and cost-effectiveness of intervention. Significantly more people involved in priority setting preferred the consideration of cost-effectiveness of intervention. However, in the three scenarios, a majority of the survey respondents gave greatest weight to treating the severely ill patient compared to the one with a more cost-effective intervention. There was also general agreement on treating the more severely ill patient with less cost-effective treatment. No significant differences were noted between the responses.
We found widespread concern for severity of disease relative to cost-effectiveness. This is comparable to findings in context with relatively more resources but requires more investigation, especially with a wider variety of relevant respondents
International Journal for Equity in Health 2003, 2: 11 (published 29 December 2003)
Uses of population census data for monitoring geographical imbalance in the health workforce: snapshots from three developing countries
Neeru Gupta, Pascal Zurn, Khassoum Diallo and Mario R Dal Poz
Imbalance in the distribution of human resources for health (HRH), eventually leading to inequities in health services delivery and population health outcomes, is an issue of social and political concern in many countries. However, the empirical evidence to support decision-making is often fragmented, and many standard data sources that can potentially produce statistics relevant to the issue remain underused, especially in developing countries. This study investigated the uses of demographic census data for monitoring geographical imbalance in the health workforce for three developing countries, as a basis for formulation of evidence-based health policy options.
Population-based indicators of geographical variations among HRH were extracted from census microdata samples for Kenya, Mexico and Viet Nam. Health workforce statistics were matched against international standards of occupational classification to control for cross-national comparability. Summary measures of inequality were calculated to monitor the distribution of health workers across spatial units and by occupational group.
Strong inequalities were found in the geographical distribution of the health workforce in all three countries, with the highest densities of HRH tending to be found in the capital areas. Cross-national differences were found in the magnitude of distributional inequality according to occupational group, with health professionals most susceptible to inequitable distribution in Kenya and Viet Nam but less so in Mexico compared to their associate professional counterparts. Some discrepancies were suggested between mappings of occupational information from the raw data with the international system, especially for nursing and midwifery specializations.
The problem of geographical imbalance among HRH across countries in the developing world holds important implications at the local, national and international levels, in terms of constraints for the effective deployment, management and retention of HRH, and ultimately for the equitable delivery of health services. A number of advantages were revealed of using census data in health research, notably the potential for producing detailed statistics on health workforce characteristics at the sub-national level. However, lack of consistency in the compilation and processing of occupational information over time and across countries continues to hamper comparative analyses for HRH policy monitoring and evaluation.
Environmental Health: A Global Access Science Source 2003 2: 13 (published 3 November 2003)
Can an Hour or Two of Sun Protection Education A Year Keep the Sunburn Away?
Alan C Geller, Linda Rutsch, Kristin Kenausis, Paula Selzer and Zi Zhang
Melanoma incidence is rising at a rate faster than any other preventable cancer in the United States. Childhood exposure to ultraviolet (UV) light increases risk for skin cancer as an adult, thus starting positive sun protection habits early may be key to reducing the incidence of this disease.
The Environmental Protection Agency's SunWise School Program, a national environmental and health education program for sun safety of children in primary and secondary schools (grades K-8) was evaluated with surveys administered to participating students.
Pretests (n=5,625) and posttests (n=5,028) were completed by students in 102 schools in 42 states. Significant improvement was noted for the three knowledge variables. Intentions to play in the shade increased from 68% to 75%(p < 0.001) with more modest changes in intentions to use sunscreen. Attitudes regarding healthiness of a tan also decreased significantly.
Brief, standardized sun protection education can be efficiently interwoven into existing school curricula, and result in improvements in knowledge and positive intentions for sun protection.
Malaria Journal 2003 2: 36 (published 4 November 2003)
Challenges in using Geographic Information Systems (GIS) to understand and manage malaria in Indonesia
Neil G Sipe and Pat Dale
Malaria is a mosquito-borne disease of global concern with 1.5 to 2.7 million people dying each year and many more suffering from it. In Indonesia, malaria is a major public health issue with around 6 million clinical cases and 700 deaths each year. Malaria is most prevalent in the developing countries of the world. Aid agencies have provided financial and technical assistance to malaria-prone countries in an effort to battle the disease. Over the past decade, the focus of some of this assistance has been in the provision of geographic information systems (GIS) hardware, software and training. In theory, GIS can be a very effective tool in combating malaria, however in practice there have been a host of challenges to its successful use.
This review is based, in part, on the literature but also on our experience working with the Indonesia Ministry of Health. The review identifies three broad problem areas. The first of these relates to data concerns. Without adequate data, GIS is not very useful. Specific problem areas include: accurate data on the disease and how it is reported; basic environmental data on vegetation, land uses, topography, rainfall, etc.; and demographic data on the movement of people. The second problem area involves technology - specifically computer hardware, GIS software and training. The third problem area concerns methods - assuming the previous data and technological problems have been resolved how can GIS be used to improve our understanding of malaria? One of the main methodological tools is spatial statistical analysis, however this is a newly developing field, is not easy to understand and suffers from the fact that there is no agreement on standard methods of analysis.
The paper concludes with a discussion of strategies that can be used to overcome some of these problems. One of these strategies involves using ArcView GIS software in combination with ArcExplorer (a public domain program that can read ArcView files) to deal with the problem of needing multiple copies of GIS software. Another way of dealing with high software cost and training is to speed the introduction of the HealthMapper software to Indonesia. This GIS software is available to public health departments at no cost from the World Health Organisation. In combination with HealthMapper, a self-paced training package should be developed for training health professionals on how to use GIS with a specific focus on understanding and controlling malaria.
Malaria Journal 2003, 2: 43
Improving ability to identify malaria and correctly use chloroquine in children at household level in Nakonde District, Northern Province of Zambia
Frederick AD Kaona and Mary Tuba
Mwengu Social and Health Research Centre, 12 Kafupi Road, Plot Number 1410/130 Northrise, P O Box 73693, Ndola-Zambia
This study investigated causes of malaria and how cases were managed at household level, in order to improve the ability to identify malaria and ensure correct use of chloroquine. It was conducted in Nakonde District, Northern Province of Zambia, between 2000 and 2001. Nakonde district is in a hyperendemic malaria province, where Plasmodium falciparum is predominant. The district has a total population of 153, 548 people, the majority of whom are peasant farmers. The main aim of the post intervention survey was to establish the proportion of caretakers of children five years and below, who were able to identify simple and severe malaria and treat it correctly using chloroquine in the home.
A baseline survey was conducted in five wards divided into intervention and control.
Intervention and control wards were compared. Village health motivators and vendors were identified and trained in three intervention wards, as a channel through which information on correct chloroquine dose could be transmitted. A total of 575 carers, who were 15 years old and above and had a child who had suffered from malaria 14 days before the survey commenced, were interviewed. The two control wards received no intervention. 345 caretakers were from the intervention wards, while 230 came from the control wards. Identification of malaria and correct use of anti-malarial drugs was assessed in terms of household diagnosis of malaria in children under five years, type and dose of anti-malarial drugs used, self medication and the source of these anti-malarials.
The majority of respondents in the study were females (81%). Chloroquine was the most frequently used anti-malarial (48.5%) in both the intervention and control wards. There was no difference between the intervention and control wards at pre-intervention (P = 0.266 and P = 0.956), in the way mothers and other caretakers identified simple and severe malaria. At baseline, knowledge on correct chloroquine dosage in the under five children was comparable between intervention and control wards. Post-intervention revealed that mothers and other caretakers were 32% and 51%, respectively, more likely to identify simple and severe malaria. There was a 60% increase on correct chloroquine dosage in all age groups among carers living in post-intervention wards.
Compliance with standard therapeutic doses and correct identification of malaria was poorest in control wards, where no motivators and vendors were trained.
Malaria Journal 2003, 2: 42
Is the Mbita trap a reliable tool for evaluating the density of anopheline vectors in the highlands of Madagascar?
Rémi Laganier1, Fara M Randimby1, Voahirana Rajaonarivelo1, 2 and Vincent Robert1, 2
1Unité d'Entomologie Médicale, Groupe de Recherche sur le Paludisme, Institut Pasteur de Madagascar, B.P. 1274, Antananarivo 101, Madagascar
2UR Paludisme afro-tropical, Institut de Recherche pour le Développement, B.P. 434, Antananarivo 101, Madagascar
One method of collecting mosquitoes is to use human beings as bait. This is called human landing collection and is a reference method for evaluating mosquito density per person. The Mbita trap, described by Mathenge et al in the literature, consists of an entry-no return device whereby humans are used as bait but cannot be bitten. We compared the Mbita trap and human landing collection in field conditions to estimate mosquito density and malaria transmission.
Our study was carried out in the highlands of Madagascar in three traditional villages, for 28 nights distributed over six months, with a final comparison between 448 men-nights for human landing and 84 men-nights for Mbita trap, resulting in 6,881 and 85 collected mosquitoes, respectively.
The number of mosquitoes collected was 15.4 per human-night and 1.0 per trap-night, i.e. an efficiency of 0.066 for Mbita trap vs. human landing. The number of anophelines was 10.30 per human-night and 0.55 per trap-night, i.e. an efficiency of 0.053. This efficiency was 0.10 for indoor Anopheles funestus, 0.24 for outdoor An. funestus, and 0.03 for Anopheles arabiensis. Large and unexplained variations in efficiency were observed between villages and months.
In the highlands of Madagascar with its unique, highly zoophilic malaria vectors, Mbita trap collection was poor and unreliable compared to human landing collections, which remains the reference method for evaluating mosquito density and malaria transmission. This conclusion, however, should not be extrapolated directly to other areas such as tropical Africa, where malaria vectors are consistently endophilic.
Malaria Journal 2003, 2: 41
Induction of HO-1 in tissue macrophages and monocytes in fatal falciparum malaria and sepsis
Ian A Clark1, Melissa M Awburn1, Clive G Harper2, N George Liomba3 and Malcolm E Molyneux4, 5
1Dept of Biochemistry, Australian National University, Canberra, Australia
2Dept of Pathology, University of Sydney, Australia
3Dept of Histopathology, College of Medicine, University of Malawi, Blantyre, Malawi
4Wellcome Trust Laboratories and Malaria Project, College of Medicine, University of Malawi
5School of Tropical Medicine, University of Liverpool, UK
As well as being inducible by haem, haemoxygenase -1 (HO-1) is also induced by interleukin-10 and an anti-inflammatory prostaglandin, 15d PGJ2, the carbon monoxide thus produced mediating the anti-inflammatory effects of these molecules. The cellular distribution of HO-1, by immunohistochemistry, in brain, lung and liver in fatal falciparum malaria, and in sepsis, is reported.
Wax sections were stained, at a 1:1000 dilution of primary antibody, for HO-1 in tissues collected during paediatric autopsies in Blantyre, Malawi. These comprised 37 acutely ill comatose patients, 32 of whom were diagnosed clinically as cerebral malaria and the other 5 as bacterial diseases with coma. Another 3 died unexpectedly from an alert state. Other control tissues were from Australian adults.
Apart from its presence in splenic red pulp macrophages and microhaemorrhages, staining for HO-1 was confined to intravascular monocytes and certain tissue macrophages. Of the 32 clinically diagnosed cerebral malaria cases, 11 (category A) cases had negligible histological change in the brain and absence of or scanty intravascular sequestration of parasitized erythrocytes. Of these 11 cases, eight proved at autopsy to have other pathological changes as well, and none of these eight showed HO-1 staining within the brain apart from isolated moderate staining in one case. Two of the three without another pathological diagnosis showed moderate staining of scattered monocytes in brain vessels. Six of these 11 (category A) cases exhibited strong lung staining, and the Kupffer cells of nine of them were intensely stained. Of the seven (category B) cases with no histological changes in the brain, but appreciable sequestered parasitised erythrocytes present, one was without staining, and the other six showed strongly staining, rare or scattered monocytes in cerebral vessels. All six lung sections not obscured by neutrophils showed strong staining of monocytes and alveolar macrophages, and all six available liver sections showed moderate or strong staining of Kupffer cells. Of the 14 (category C) cases, in which brains showed micro-haemorrhages and intravascular mononuclear cell accumulations, plus sequestered parasitised erythrocytes, all exhibited strong monocyte HO-1 staining in cells forming accumulations and scattered singly within cerebral blood vessels. Eleven of the available and readable 13 lung sections showed strongly staining monocytes and alveolar macrophages, and one stained moderately. All of the 14 livers had strongly stained Kupffer cells. Of five cases of comatose culture-defined bacterial infection, three showed a scattering of stained monocytes in vessels within the brain parenchyma, three had stained cells in lung sections, and all five demonstrated moderately or strongly staining Kupffer cells. Brain sections from all three African controls, lung sections from two of them, and liver from one, showed no staining for HO-1, and other control lung and liver sections showed few, palely stained cells only. Australian-origin adult brains exhibited no staining, whether the patients had died from coronary artery disease or from non-infectious, non-cerebral conditions
Clinically diagnosed 'cerebral malaria' in children includes some cases in whom malaria is not the only diagnosis with the hindsight afforded by autopsy. In these patients there is widespread systemic inflammation, judged by HO-1 induction, at the time of death, but minimal intracerebral inflammation. In other cases with no pathological diagnosis except malaria, there is evidence of widespread inflammatory responses both in the brain and in other major organs. The relative contributions of intracerebral and systemic host inflammatory responses in the pathogenesis of coma and death in malaria deserve further investigation.