The effect of text message support on diabetes self-management in developing countries - A randomised trial.

OBJECTIVE: mHealth interventions have the potential to facilitate self-management. This TEXT4DSM study implemented a mobile phone intervention in existing diabetes programmes in three low- and middle-income countries (Democratic Republic of Congo, Cambodia, and the Philippines). RESEARCH DESIGN AND METHODS: Sub-studies with a similar randomised controlled trial design were conducted in three different countries. Each sub-study included 480 adults with diabetes. Subjects were randomised to receive either routine care or routine care plus text message self-management support. The primary outcome was the difference in the proportion of subjects with well-controlled diabetes after 2 years. RESULTS: Baseline and 2-year HbA1c measurements were available for 781 individuals. After 2 years, the proportion of subjects with controlled HbA1c was 2.8% higher in the intervention group than in the control group (difference not statistically significant). In the logistic regression model, the odds ratio for having controlled diabetes after the intervention was 1.1, after adjusting for baseline HbA1c level, sex, receiving insulin treatment, and participating in the routine programme. The HbA1c dynamics over time differed between programmes; the number of people with controlled diabetes tended to increase in DR Congo and decrease in Cambodia. CONCLUSION: This study was the first to test the same mHealth intervention in different countries. The finding that text messages did not show an additional effect on diabetes control implied that expectations about mHealth should be cautious. The degree of coverage, the quality of the routine programme, and the progression of disease can interfere with the expected impact. Trial registration: ISRCTN registry (86247213).

Process evaluation of a mobile health intervention for people with diabetes in low income countries - the implementation of the TEXT4DSM study.

Introduction Evidence about mobile health (mHealth) approaches to manage diabetes shows modest effects on outcomes, but little is known about implementation variability. This is a process evaluation of an mHealth intervention to improve diabetes self-management through Short Message Service (SMS) provision in three diabetes care programmes in the Democratic Republic of Congo (DRC), Cambodia and the Philippines. Methods The intervention involved Diabetes Self-Management Support via text messages. The content and process of the intervention is based upon the core principles of diabetes self-management and behaviour theory. In each country, messages were sent by project managers to 240 participants in each country, who were randomly assigned to the intervention group. Contracts were negotiated with national phone providers and open access software was used to send the messages. Participants received a mobile phone and SIM card. We analysed data about the implementation process over a one year period. Results The mean monthly number of messages delivered to recipients' phones was 67.7% of the planned number in DRC, 92.3% in Cambodia and 83.9% in the Philippines. A telephone check revealed problems with one-third of the phones, including breakage, loss and cancelled subscriptions. The number of people reached at least once was 177 (70.0%) in DRC; 147 (60.7%) in Cambodia; five in the Philippines (2.0%). Those reached each time was 144 in DRC (56.9%), 28 (9.9%) in Cambodia, none in the Philippines. People used their phone more frequently than before the intervention. Discussion Implementation of the intervention meets constraints at every step in the process. Barriers relate to the technology, the context and the participants.

Forty years of USAID health cooperation in Bolivia. A lose-lose game?

The present article proposes an analysis of the USA-Bolivia relationships in the health sector between 1971 and 2010 based on a grey and scientific literature review and on interviews. We examined United States Agency for International Development (USAID) interventions, objectives, consistency with Bolivian needs, and impact on health system integration. USAID operational objectives--decentralization, fertility and disease control, and maternal and child health--may have worked against each other while competing for limited Ministry of Health resources. They largely contributed to the segmentation and fragmentation of the Bolivian health system. US cooperation in health did not significantly improve health status while the USAID failed to properly tackle anti-drugs, political, and economic US interests in Bolivia.

The effectiveness of text messages support for diabetes self-management: protocol of the TEXT4DSM study in the democratic Republic of Congo, Cambodia and the Philippines.

BACKGROUND: People with diabetes find it difficult to sustain adequate self-management behaviour. Self-Management Support strategies, including the use of mobile technology, have shown potential benefit. This study evaluates the effectiveness of a mobile phone support intervention on top of an existing strategy in three countries, DR Congo, Cambodia and the Philippines to improve health outcomes, access to care and enablement of people with diabetes, with 480 people with diabetes in each country who are randomised to either standard support or to the intervention. DESIGN/METHODS: The study consists of three sub-studies with a similar design in three countries to be independently implemented and analysed. The design is a two-arm Randomised Controlled Trial, in which a total of 480 adults with diabetes participating in an existing DSME programme will be randomly allocated to either usual care in the existing programme or to usual care plus a mobile phone self-management support intervention. Participants in both arms complete assessments at baseline, one year and two years after inclusion.Glycosylated haemoglobin blood pressure, height, weight, waist circumference will be measured. Individual interviews will be conducted to determine the patients' assessment of chronic illness care, degree of self-enablement, and access to care before implementation of the intervention, at intermediate moments and at the end of the study.Analyses of quantitative data including assessment of differences in changes in outcomes between the intervention and usual care group will be done. A probability of <0.05 is considered statistically significant. Outcome indicators will be plotted over time. All data are analysed for confounding and interaction in multivariate regression analyses taking potential clustering effects into account.Differences in outcome measures will be analysed per country and realistic evaluation to assess processes and context factors that influence implementation in order to understand why it works, for whom, under which circumstances. A costing study will be performed. DISCUSSION: The intervention addresses the problem that the greater part of diabetes management takes place without external support and that many challenges, unforeseen problems and questions occur at moments in between scheduled contacts with the support system, by exploiting communication technology. TRIAL REGISTRATION: ISRCTN86247213.

[Epidemiological environment and response to the HIV epidemic in Bolivia]. / Entorno epidemiológico y respuesta a la epidemia del VIH en Bolivia.

With AIDS/HIV, early detection is of key importance to public health, as well as disseminating prevention information and providing timely and appropriate treatment. In Bolivia, at the end of 2006 approximately 50% had AIDS at the time of diagnosis, detection having occurred late in the illness. The HIV/AIDS epidemic in Bolivia is concentrated, with prevalence rates over 5% among the at-risk population, primarily men who have sex with men. From January 1984 through October 2006, the total number of HIV/AIDS cases reported in Bolivia rose to 2 190, with 1 239 HIV and 951 AIDS cases, and underreporting estimated to be over 70% country-wide. The United National Joint Program on AIDS (UNAIDS) estimated that by the end of 2006 there would be 6 700 people living with HIV/AIDS in Bolivia. In the context of this scenario, the article describes the challenges facing the HIV/AIDS program and the strategies developed to address the epidemic in Bolivia. In addition, the UNAIDS/PAHO strategies are stressed and must get underway for HIV/AIDS prevention and control activities in the country.

Entorno epidemiológico y respuesta a la epidemia del VIH en Bolivia / Epidemiological environment and response to the HIV epidemic in Bolivia

With AIDS/HIV, early detection is of key importance to public health, as well as disseminating prevention information and providing timely and appropriate treatment. In Bolivia, at the end of 2006 approximately 50 percent had AIDS at the time of diagnosis, detection having occurred late in the illness. The HIV/AIDS epidemic in Bolivia is concentrated, with prevalence rates over 5 percent among the atrisk population, primarily men who have sex with men. From January 1984 through October 2006, the total number of HIV/AIDS cases reported in Bolivia rose to 2 190, with 1 239 HIV and 951 AIDS cases, and underreporting estimated to be over 70 percent country-wide. The United National Joint Program on AIDS (UNAIDS) estimated that by the end of 2006 there would be 6 700 people living with HIV/AIDS in Bolivia. In the context of this scenario, the article describes the challenges facing the HIV/AIDS program and the strategies developed to address the epidemic in Bolivia. In addition, the UN-AIDS/PAHO strategies are stressed and must get underway for HIV/AIDS prevention and control activities in the country.

Satisfacción de usuarios de los servicios de salud: Factores sociodemográficos y de accesibilidad asociados / Peruvian health services user's satisfaction: socio-demographic factors and accessibility. Peru 2000

Objetivos: Determinar el nivel de satisfacción del usuario (SU) en centros de salud (CS) y hospitales del MINSA; analizar la relación entre SU y nivel socioeconómico (NSE); e identificar los factores sociodemográficos y de accesibilidad asociados. Materiales y Métodos: Análisis secundario de los datos de Encuesta Nacional de Niveles de Vida (ENNIV) 2000. Fueron entrevistados 376 y 327 usuarios de los CS y hospitales, respectivamente. Las variables de estudio fueron SU, niveles socioeconómico y características sociodemográficas y accesibilidad para la atención. Se aplicó estadística descriptiva y multivariada. Resultados: Los usuarios de los establecimientos muestran características diferenciadas. La SU fue 68,1 por ciento y 62,1 por ciento para los CS y hospitales, respectivamente. Los usuarios de menor NSE presentaron mayor satisfacción. La edad, educación, distancia al establecimiento y el tiempo de espera presentan asociaciones con la SU. Conclusiones: Existen factores sociodemográficos, económicos y de accesibilidad para la atención, que muestran relación con la satisfacción del usuario; tales factores se comportan de manera particular según el tipo de establecimiento de salud (centro de salud, hospital), debido fundamentalmente a que la población usuaria es distinta. Esto último relativiza la comparación del nivel de satisfacción y de sus factores asociados entre tales establecimientos.

Bioética y salud pública: el cruce de los caminos / Crossroads of bioethics and public health

En su desarrollo respectivo, tanto la ética médica y, luego, la bioética como la salud pública han llegado a unpunto de encuentro. Este proceso se traduce en una puesta en tensión de los principios fundadores de la bioética, debido a las contradicciones que surgen entre lo individual y lo social. Sin embargo, la búsqueda de nuevos valores puede ayudar a enfocar esta aparente oposición. En este recorrido, la bioética trae consigo su valioso método de debate abierto y contradictorio, mientras la salud pública presenta una tradición de organización de las acciones sanitarias basada enconceptos sociales (solidaridad, responsabilidad, interculturalidad). Esto permite reflexionar, además, a propósito de las condiciones concretas del ejercicio de la bioética en los servicios de salud.

[Information for health equity in Chile]. / Informacion para la equidad en salud en Chile .

OBJECTIVES: To estimate the magnitude of geographical health inequalities in Chile through key indicators based on data and information that are routinely collected and easily obtained, and to characterize the current situation with respect to the availability, quality, and access to information on health equity that official sources routinely collect. METHODS: A conceptual framework proposed by the World Health Organization was used to study health equity in terms of four dimensions: 1) state of health, 2) health determinants, 3) resources for and the supply of health system services, and 4) utilization of health system services. For each of these four dimensions, indicators were selected for which there was available information. The information was aggregated according to geographical and administrative units in the country: communes (342 in Chile), sanitary districts called "Health Services" (28), and regions (13). The aggregated information was analyzed using univariate analysis (distribution characteristics), bivariate analysis (correlations and frequency tables), and tabulation of values for selected indicators for the communes. RESULTS: With respect to the first dimension, state of health, we found an inverse relationship between mortality and average family income in the communes (r = -0.24; P < 0.001; n = 191 communes). With health determinants, there were important differences among the communes with regard to average household income, years of schooling, literacy, quality of housing, drinking water supply, and the wastewater disposal system. In terms of resources for and the supply of health system services, the municipal governments of the communes with higher average household incomes tended to contribute more funds per beneficiary (r = 0.19; P = 0.013). The financial contributions from the national government were targeted well, but they only partially compensated for the more limited resources available in poorer communes. With respect to the utilization of health care services per beneficiary in the different sanitary districts, we found some large differences. In terms of the ratio between the highest rate of utilization in any of the districts and the lowest rate in any other district, the ratio for primary-care visits per beneficiary was 2.8, the ratio for emergency-care visits was 3.9, and the ratio for hospitalizations was 2.0. CONCLUSIONS: There are important geographical differences in Chile with respect to mortality and other health outcomes, income and environmental conditions, and the financing and utilization of health care services. The information that is collected regularly and is available to characterize the health-related variables frequently has limitations in terms of quality, sustainability, and access. In Chile it would be pointless to focus the greatest efforts on reorganizing the information systems. The existing indicators showing marked inequalities are adequate to support the planning of interventions aimed at making urgently needed improvements in the situation of the worst-off Chileans.

Información para la equidad en salud en Chile / Information for health equity in Chile

Objectives. To estimate the magnitude of geographical health inequalities in Chile through key indicators based on data and information that are routinely collected and easily obtained, and to characterize the current situation with respect to the availability, quality, and access to information on health equity that official sources routinely collect. Methods. A conceptual framework proposed by the World Health Organization was used to study health equity in terms of four dimensions: 1) state of health, 2) health determinants, 3) resources for and the supply of health system services, and 4) utilization of health system services. For each of these four dimensions, indicators were selected for which there was available information. The information was aggregated according to geographical and administrative units in the country: communes (342 in Chile), sanitary districts called "Health Services" (28), and regions (13). The aggregated information was analyzed using univariate analysis (distribution characteristics), bivariate analysis (correlations and frequency tables), and tabulation of values for selected indicators for the communes. Results. With respect to the first dimension, state of health, we found an inverse relationship between mortality and average family income in the communes (r = ­0.24; P < 0.001; n = 191 communes). With health determinants, there were important differences among the communes with regard to average household income, years of schooling, literacy, quality of housing, drinking water supply, and the wastewater disposal system. In terms of resources for and the supply of health system services, the municipal governments of the communes with higher average household incomes tended to contribute more funds per beneficiary (r = 0.19; P = 0.013). The financial contributions from the national government were targeted well, but they only partially compensated for the morelimited resources available in poorer communes. With respect to the utilization of health care services per beneficiary in the different sanitary districts, we found some large differences. In terms of the ratio between the highest rate of utilization in any of the districts and the lowest rate in any other district, the ratio for primary-care visits per beneficiary was 2.8, the ratio for emergency-care visits was 3.9, and the ratio for hospitalizations was 2.0. Conclusions. There are important geographical differences in Chile with respect to mortality and other health outcomes, income and environmental conditions, and the financing and utilization of health care services. The information that is collected regularly and is available to characterize the health-related variables frequently has limitations in terms of quality, sustainability, and access. In Chile it would be pointless to focus the greatest efforts on reorganizing the information systems. The existing indicators showing marked inequalities are adequate to support the planning of interventions aimed at making urgently needed improvements in the situation of the worst-off Chileans

Objetivos. Estimar la magnitud de las desigualdades geográficas de salud en Chile mediante indicadores clave basados en datos e información de fácil obtención recolectada de forma rutinaria, y caracterizar la situación actual con respecto a la disponibilidad, calidad y accesibilidad de la información sobre equidad en salud recolectada de forma rutinaria por fuentes oficiales. Métodos. Se usó un marco conceptual propuesto por la Organización Mundial de la Salud para el estudio de la equidad en salud que consta de cuatro dimensiones: I. estado de salud, II. determinantes de la salud, III. recursos y oferta del sistema de salud, y IV. utilización de servicios del sistema de salud. Para cada una de estas dimensiones se hizo una selección de indicadores para los cuales existía información disponible. La información, agregada por unidad geográfica (comuna, Servicio de Salud o región), fue analizada usando los siguientes métodos: análisis univariado (características de las distribuciones); análisis bivariado (correlaciones y tablas de frecuencia); tabulación de valores comunales para indicadores seleccionados. Resultados. Estado de salud: encontramos una relación inversa entre la mortalidad y el ingreso familiar medio en la comuna (r = ­0,24; P < 0,001; n = 191 comunas). Determinantes de la salud: hay importantes variaciones entre las comunas con respecto al ingreso doméstico medio, años de escolarización, analfabetismo, calidad de la vivienda, abastecimiento de agua potable y sistemas de eliminación de aguas residuales. Recursos y oferta del sistema de salud: los gobiernos municipales de las comunas con mayores ingresos domésticos medios tienden a aportar mayores recursos financieros por beneficiario (r = 0,19; P = 0,0130). El aporte del gobierno central, aunque se encuentra bien orientado, solo compensa parcialmente esta situación en beneficio de las comunas pobres. Utilización de servicios de atención de salud: entre los servicios de salud, el uso de los servicios de atención médica en el nivel primario es 2,8 veces mayor en unos que en otros, la atención médica de urgencia 3,9 veces mayor, y los egresos hospitalarios 2 veces más numerosos. Conclusiones. Existen importantes variaciones geográficas en lo que se refiere a la mortalidad y a otros resultados de salud, en ingresos y condiciones ambientales, y en el financiamiento y utilización de los servicios de asistencia sanitaria. La información recolectada regularmente y que se encuentra disponible para caracterizar las variables relacionadas con la salud presenta con cierta frecuencia limitaciones de calidad, sostenibilidad o accesibilidad. En el contexto chileno, sería infructuoso centrar los mayores esfuerzos en la reorganización de los sistemas de información, toda vez que las pruebas ya existentes de marcadas desigualdades son suficientes para apoyar la planificación de intervenciones orientadas a mejorar con urgencia la situación de los chilenos más desprotegidos

Diferencias de mortalidad infantil dentro de Bolivia / Differences in infant death rates within Bolivia

El descenso de la mortalidad infantil registrado en Bolivia entre los censos nacionales de población de 1976 y 1992 encubre en realidad tendencias diferentes entre departamentos, así como entre zonas urbanas y rurales. Para poner de manifiesto esta situación, en 1996 se aplicó el análisis de las diferencias de mortalidad reducibles, que consiste en comparar la tasa de mortalidad infantil de cada departamento del país con la tasa mínima observada en los demás departamentos y calcular la reducción posible considerando comportamientos idénticos entre departamentos. Se procedió de manera similar para comparar las zonas urbanas con las rurales. Los resultados muestran que en cuatro departamentos de Bolivia (Beni, Oruro, Pando y Potosí) hubo un aumento de las diferencias de mortalidad en relación con los demás departamentos. Es decir, que en esos departamentos la mortalidad infantil no se ha reducido como era de esperar teniendo en cuenta la evolución general de ese indicador en el país. Asimismo, las zonas rurales de todos los departamentos tienen diferenciales negativas en relación con las zonas urbanas. La cuantificación de esas diferencias permite proponer metas para la política nacional de desarrollo humano sostenible

Diferencias de mortalidad infantil dentro de Bolivia / Differences in infant death rates within Bolivia

El descenso de la mortalidad infantil registrado en Bolivia entre los censos nacionales de población de 1976 y 1992 encubre en realidad tendencias diferentes entre departamentos, así como entre zonas urbanas y rurales. Para poner de manifiesto esta situación, en 1996 se aplicó el análisis de las diferencias de mortalidad reducibles, que consiste en comparar la tasa de mortalidad infantil de cada departamento del país con la tasa mínima observada en los demás departamentos y calcular la reducción posible considerando comportamientos idénticos entre departamentos. Se procedió de manera similar para comparar las zonas urbanas con las rurales. Los resultados muestran que en cuatro departamentos de Bolivia (Beni, Oruro, Pando y Potosí) hubo un aumento de las diferencias de mortalidad en relación con los demás departamentos. Es decir, que en esos departamentos la mortalidad infantil no se ha reducido como era de esperar teniendo en cuenta la evolución general de ese indicador en el país. Asimismo, las zonas rurales de todos los departamentos tienen diferenciales negativas en relación con las zonas urbanas. La cuantificación de esas diferencias permite proponer metas para la política nacional de desarrollo humano sostenible

There was an overall decrease in infant mortality in Bolivia between the national censuses of 1976 and of 1992. That general pattern, however, in fact conceals differences in trends from one department to another, as well as between urban and rural areas. In order to elucidate this situation, in 1996 the reducible differences in mortality were analyzed. This was done by comparing the infant mortality rate in each department of the country with the lowest rate found in the other departments and calculating the possible reduction if all the departments had had the same level of achievement. Using a similar approach, urban areas were compared with rural ones. The results show that in four departments of Bolivia (Beni, Oruro, Pando, and Potosí) the differences in mortality rates increased in comparison to the other departments. That is, in those four departments infant mortality has not fallen as much as could be expected given the general trends in the country. Similarly, the decline in infant mortality rates in the rural areas has lagged behind the decreases seen in urban areas. Quantifying these differences makes it possible to propose goals for the national policy of sustainable human development