Ethics and electronic health information technology: challenges for evidence-based medicine and the physician-patient relationship.

OBJECTIVES: The National Health Insurance Scheme (NHIS), and the National Identification Authority (NIA), pose ethical challenges to the physician-patient relationship due to interoperability. This paper explores (1) the national legislation on Electronic Health Information Technology (EHIT), (2) the ethics of information technology and public health and (3) the effect on the Physician-patient relationship. METHOD: This study consisted of systematic literature and internet review of the legislation, information technology, the national health insurance program, and the physician-patient relationship. RESULT: The result shows that (1) EHIT have eroded a big part of the confidentiality between the physician and patient; (2) The encroachment on privacy is an inevitable outcome of EHIT; (3) Legislation on privacy, the collection, storage and uses of electronic health information is needed and; (4) the nexus between EHIT, NHIS, NHA, Ethics, the physician-patient relationship and privacy. CONCLUSION: The study highlights the lack of protection for physician-patient relationship as medical practice transitions from the conventional to the modern, information technology driven domain.

The Gambian National Impregnated Bednet Programme: costs, consequences and net cost-effectiveness.

Clinical trials have indicated that treating mosquito nets with insecticide could be a potentially cost-effective method of preventing malaria. As malaria is one of the most common causes of death in children under five in developing countries, there has been substantial interest in whether such findings can be replicated for a country's control programme in practice. The cost-effectiveness of the Gambian National Insecticide-impregnated Bednet Programme (NIBP), from the viewpoint of providers (government and non-governmental agencies) and the community, has been calculated. Information was collected from existing records, interviews with NIBP personnel, observation and household surveys. Information is provided on the resource use consequences of the NIBP in terms of reduced expenditure on anti-malaria preventive measures, treatment in government health services, household financed treatment and "charity" (burial, funeral and mourning activities), as well as cash income lost as a result of child death. The annual implementation cost of the NIBP was D757,875 (US$91,864), of which 86% was recurrent cost. The estimated number of death averted was 40.56. The net implementation cost-effectiveness ratio per death averted and discounted life years gained were D3884 (US$471) and D260 (US$31.5), respectively. Adding the cost of all mosquito nets would increase the cost-effectiveness ratios by over five times, which is an important consideration for countries with a lower coverage of mosquito nets per capita. It is concluded that insecticide-impregnated mosquito nets are one of the more efficient ways of reducing deaths in children under 10 years in rural Gambia.

The economic burden of lymphatic filariasis in northern Ghana.

The socio-economic impact of lymphatic filariasis was investigated in a rural community in northern Ghana, as part of a multi-country study. The entire community was followed up for a period of one full calendar year, to document episodes of acute adenolymphangitis (ADL), treatment seeking and the cost of treatment. Cases of chronic filarial disease identified at the start of the study were also visited every 3 months to monitor treatment seeking and the costs of treatment. The subjects, who were mainly subsistence farmers, were found to be materially very poor. The incidence of ADL, which lasted an average of 5 days, was found to be very high. Most of those affected were unable to perform their normal activities for much of the ADL episode. In general, most subjects with long-standing chronic disease, such as elephantiasis of the leg and hydroceles, tended not to seek treatment except when there was superimposed ADL. Some aspects of treatment seeking, the cost of treatment, the burden of the disease on the community, and the public-health implications are discussed.

Mortality and morbidity from malaria in Gambian children after introduction of an impregnated bednet programme.

After the success of a controlled trial of insecticide-treated bednets in lowering child mortality, The Gambia initiated a National Insecticide Impregnated Bednet Programme (NIBP) in 1992 with the objective of introducing this form of malaria control into all large villages in The Gambia. Five areas (population 115,895) were chosen as sentinel sites for evaluation of the NIBP. During the first year of intervention a 25% reduction was achieved in all-cause mortality in children 1-9 years old living in treated villages (rate ratio 0.75 [95% CI 0.57-0.98], p = 0.04). If one area where the programme was ineffective was excluded, the reduction was 38% (0.62 [0.46-0.83), p = 0.001). A decrease in rates of parasitaemia and high-density parasitaemia, an increase in mean packed-cell volume (rate ratio 0.75 [95% CI 0.59-0.98], p = 0.04) and an improvement in the nutritional status of children living in treated villages were also detected. In a country such as The Gambia, where nets were widely used and which has a good primary health care system, it is possible to achieve insecticide-treatment of bednets at a national level with a significant reduction in child mortality; but at a cost which the country cannot afford.

Attitudes to malaria, traditional practices and bednets (mosquito nets) as vector control measures: a comparative study in five west African countries.

Five West African communities were visited to assess the knowledge of the cause of malaria and to document traditional ways of treating and preventing the infection. Knowledge of the cause of malaria was low in the five communities visited. People were more concerned about mosquitoes being a nuisance than a cause of the infection. Various herbs were used as mosquito repellents. Malaria was treated by a number of traditional practices, including herbal remedies. Bednets were used to a varying extent, from 44% Ghana to 86% Gambia, in each community to protect against mosquito bites but also for other purposes such as privacy, decoration and protection from roof debris dropping on the bed.

PIP: A previous study among Gambian children aged 1-4 years found that overall mortality was reduced by 63% after use of insecticide-treated bednets. In this study, the aim was to determine the degree to which bednets were used and the factors affecting their use in Farafenni, The Gambia; Navrongo in eastern Ghana; suburban Bandim outside Bissau Town, Guinea-Bissau; Niakhar in Senegal; and a rural village around Bo in Sierra Leone. Bednets were known and used to protect children from mosquito bites in the 5 West African countries; bednets were also used for privacy and to protect from falling roof debris. A structured questionnaire was administered. Background information had been collected prior to the survey administration on local terminology for symptoms of malaria, the extent of health education campaigns, availability of Western and traditional treatment regimens, use of bednets, and constraints to use. Each of the study areas was described in terms of the social and demographic characteristics of the population. The findings indicated that about 50% of people in Ghana Guinea-Bissau, and Sierra Leone were aware that mosquitoes caused malaria. Only about 25% were aware in The Gambia. Heavy rains and the cold weather that followed were also linked with malaria causes in Ghana and Guinea-Bissau. Stepping in goat urine was viewed as a cause of malaria in Senegal. In The Gambia, other causes indicated were eating of seasonally foods excessively, and an act of God. Fever was the most common symptom associated with malaria. Some differentiated in subtle ways between malaria fever and other fevers. Treatment was viewed in all countries as herbal, which was available from markets or traditional healers. About 50% of the 996 Ghana respondents used some form of traditional treatment for malaria. 86% used bednets in The Gambia and Guinea-Bissau. Only about 33% used them in Senegal, and very few used bednets in Sierra Leone and Ghana. Most were concerned about the irritation to sleep from mosquitoes. In all countries, cost of bednets was a constraint to use. Public health programs should stress the cost effectiveness and advantages of insecticide treated bednets, and information on malaria causes. Where Ghanians sleep on roofs, a new bednet design is needed.

Nationwide survey of bednet use in rural Gambia.

A nationwide survey was carried out to investigate the use of bednets in rural areas of the Gambia, particularly among children under 5 years old and among pregnant women. A stratified multistage design was used; 360 compounds in 60 villages were visited. Overall, 58% of beds had a net, with very little difference between villages with primary health care (PHC) facilities and those without (non-PHC). Bednet use was higher in the Central Region (76%) than in the Western and Eastern Regions (both 51%). It was highest among the Jola ethnic group (77%) and lowest among Sarahulis and other minority groups. Use of bednets was higher among target groups (such as infants, children under 5 years old, and pregnant women) than among the general population, and reached a level of over 90% in these groups in the Central Region. Use was associated with possession of a metal bed and a radio. Previous trials of impregnated bednets in the Gambia have been carried out in the Central Region, where bednet use is highest. The efforts of the National Impregnated Bednet Programme should therefore concentrate on the other regions and among the minority ethnic groups in order to increase bednet ownership.

A malaria control trial using insecticide-treated bed nets and targeted chemoprophylaxis in a rural area of The Gambia, west Africa. 4. Perceptions of the causes of malaria and of its treatment and prevention in the study area.

Perceptions of the causes of malaria, its treatment and prevention were studied among 996 adults, selected randomly from 73 villages and hamlets in a rural area of The Gambia. Structured questionnaires and other interview techniques were used for data collection. Malaria has no specific name in the study area; it is referred to commonly as Fula kajewo (Fula fever). Only 28% of the respondents knew that mosquitoes transmitted malaria. However, most people believed correctly that August to October was the main malaria season. Eighty-six per cent of the subjects were bed net users. The majority of nets were produced locally, usually white in colour and made of sheeting fabrics. Usage of nets was correlated with ethnic group, age and polygamy but not with education, income, occupation or ownership of certain items which indicate high social status. Analysis of expenditure on mosquito coils indicated that non-users of nets spent 43% more on coils than did users. Bed nets have been used for a long time in the study area; 98% of users saw their parents using them during their childhood.

PIP: In the Gambia, malaria specialists at the Medical Research Council Laboratories oversaw interviews of 996 men and women from, 73 villages and hamlets on the south bank of the River Gambia to learn their perceptions of the causes of malaria and of its treatment and prevention. No specific local term for malaria existed. The most common term used by all ethnic groups, except the Fulas, was Fula kejewo (Fula fever). Just 28% of all adults knew that mosquitoes transmit malaria. Men were more likely to know the real cause of malaria than women (p .001). Knowledge about the cause of malaria increased with education p =.01). Most people (90%) knew that malaria transmission occurs most often during August-October. 86% of adults and 81% of their children less than 10 years old used bed nets. Girls were more likely to sleep under bed nets than boys (p = .005). Local tailors made most bed nets with either second hand or new fabrics. They tended to be made of sheeting fabrics and white in color. Most adults were willing to treat their bed nets with the insecticide permethrin to protect against mosquitoes. Ethnic group (Fulas less likely, p .001), age (older people more likely, p .001), and polygamy (p = .002) were correlated with bed net use. Education, income, and occupation or ownership of items indicating high social status were not correlated with bed net use. Nonusers of bed nets spent 43% more on mosquito coils, used to smoke out mosquitoes from rooms before going to sleep, than did users (p = .001). Almost all adults (98%) remembers their parents using bed nets when they were children. The bed nets users who were at least 70 years old said that the Mandinkas mainly used bed nets. These findings should prove useful to the government as it develops a national impregnated bed net program to control malaria in rural areas.