The closing survival gap after liver transplantation for hepatocellular carcinoma in the United States.

BACKGROUND: Socio-economic inequalities among different racial/ethnic groups have increased in many high-income countries. It is unclear, however, whether increasing socio-economic inequalities are associated with increasing differences in survival in liver transplant (LT) recipients. METHODS: Adults undergoing first time LT for hepatocellular carcinoma (HCC) between 2002 and 2017 recorded in the Scientific Registry of Transplant Recipients (SRTR) were included and grouped into three cohorts. Patient survival and graft survival stratified by race/ethnicity were compared among the cohorts using unadjusted and adjusted analyses. RESULTS: White/Caucasians comprised the largest group (n=9,006, 64.9%), followed by Hispanic/Latinos (n=2,018, 14.5%), Black/African Americans (n=1,379, 9.9%), Asians (n=1,265, 9.1%) and other ethnic/racial groups (n=188, 1.3%). Compared to Cohort I (2002-2007), the 5-year survival of Cohort III (2012-2017) increased by 18% for Black/African Americans, by 13% for Whites/Caucasians, by 10% for Hispanic/Latinos, by 9% for patients of other racial/ethnic groups and by 8% for Asians (All P values<0.05). Despite Black/African Americans experienced the highest survival improvement, their overall outcomes remained significantly lower than other ethnic∕racial groups (adjusted HR for death=1.20; 95%CI 1.05-1.36; P=0.005; adjusted HR for graft loss=1.21; 95%CI 1.08-1.37; P=0.002). CONCLUSION: The survival gap between Black/African Americans and other ethnic/racial groups undergoing LT for HCC has significantly decreased over time. However, Black/African Americans continue to have the lowest survival among all racial/ethnic groups.

Tackling the urban health divide though enabling intersectoral action on malnutrition in Chile and Kenya.

As momentum grows for a sustainable urbanisation goal in the post-2015 development agenda, this paper reports on an action research study that sought to tackle the urban health divide by enabling intersectoral action on social determinants at the local level. The study was located in the cities of Mombasa in Kenya and Valparaíso in Chile, and the impact of the intervention on child nutrition was evaluated using a controlled design. The findings showed that an action research process using the social educational process known as PLA could effectively build the capacity of multisectoral teams to take coordinated action which in turn built the capacity of communities to sustain them. The impact on child nutrition was inconclusive and needed to be interpreted within the context of economic collapse in the intervention area. Four factors were found to have been crucial for creating the enabling environment for effective intersectoral action (i) supportive government policy (ii) broad participation and capacity building (iii) involving policy makers as advisors and establishing the credibility of the research and (iii) strengthening community action. If lessons learned from this study can be adapted and applied in other contexts then they could have a significant economic and societal impact on health and nutrition equity in informal urban settlements.

Measuring progress toward the Millennium Development Goals and the missing millions.

The 2015 target date for achieving the Millennium Development Goals (MDGs) is fast approaching, but there is very little discussion of the validity of the indicators used to measure progress. In particular, there has been little attention given to the problems that arise when assessments of progress are based on household surveys. These are inappropriate for obtaining information about the poorest of the poor. Typically, they omit by design those not in households because they are homeless; those who are in institutions; and mobile, nomadic or pastoralist populations; and, in practice, household surveys will typically under-represent those in fragile, disjointed or multiple occupancy households; and those in urban slums and insecure areas of a country. Those six subgroups constitute a pretty comprehensive ostensive definition of the "poorest of the poor." Between 300 and 500 million people--mainly in developing countries--will be missed worldwide from the sampling frames of household surveys.

What explains the distribution of doctors and nurses in different countries, and does it matter for health outcomes?

AIMS: To re-examine the form of the relationships between the global distribution of health professionals (physicians and nurses), gross national product per capita, female literacy, and infant and under-5 mortality rates reported in three papers by Robinson and Wharrad using more recent data. The secondary aim was to explore prior assumptions about the quality of the data, the homogeneity of the sample, and the form of the relationship. BACKGROUND: The analyses by Robinson and Wharrad did not take account of differences between developing and developed countries. Furthermore, the intervening years have seen changes in healthcare professional roles and their global distribution. Re-examination of these relationships is therefore timely. DESIGN: A secondary analysis of routinely collected data from international databases. METHODS: A database was constructed from Organisation for Economic Co-operation and Development, United Nations and World Bank sources on 177 countries for around 2005. Regression analyses were performed first with number of physicians and of nurses per 1000 population as dependent variables and gross national product per capita, female literacy rates, and the Gini coefficient as independent variables; and second with all those variables as independent variables and infant mortality, under-5 mortality rates, and maternal mortality rates as dependent variables. RESULTS: There were clear and interesting differences between richer (Organisation for Economic Co-operation and Development) countries and developing countries in the coefficients and in the power of the equations. CONCLUSIONS: The importance of understanding the implications of carrying out cross-country analysis and the urgent need for standardization of definitions in datasets are emphasized.

What are the reasons for high turnover in nursing? A discussion of presumed causal factors and remedies.

Problems with high turnover in nursing and of maintaining adequate numbers of nurses to supply clinical staffing requirements have a long history and have therefore attracted a commensurate literature with time. An overview and discussion of the situation internationally, with an emphasis on Organisation for Economic Co-operation and Development (OECD) countries and the UK, finds that job satisfaction is often a consistent underlying determinant interacting with workplace factors and personal reasons in complex ways. Effective and adaptive retention strategies are required to meet and mitigate the problem as reasons for it may vary over time. Solutions must be flexible and targeted to meet the individual circumstances identified.

Missing Millions and Measuring Progress towards the Millennium Development Goals with a focus on Central Asia States.

BACKGROUND: In developing countries, population estimates and assessments of progress towards the Millennium Development Goals are based increasingly on household surveys. It is not recognised that they are inappropriate for obtaining information about the poorest of the poor. This is because they, typically, omit by design: those not in households because they are homeless; those who are in institutions; and mobile, nomadic or pastoralist populations. In addition, in practice, because they are difficult to reach, household surveys will typically under-represent: those in fragile, disjointed or multiple occupancy households; those in urban slums; and may omit certain areas of a country deemed to pose a security risk. Those six sub-groups constitute a pretty comprehensive ostensive definition of the 'poorest of the poor'. METHODS: This paper documents these omissions in general, drawing on worldwide literature about the theory and practice of implementing censuses and household surveys; and shows how substantial proportions are missing from both censuses and the sample frames of surveys. RESULTS: This paper suggests that between 300 and 350 million will effectively be missed worldwide from the sampling frames of such surveys and from most censuses. The impact on the health MDGs is illustrated for the five republics of the former Soviet Union making up Central Asia: Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan. CONCLUSIONS: It is impossible to assess progress towards or away from the MDGS in both the Central Asian Republics and worldwide. It is urgent to find solutions to the problem of the 'missing' poor population sub-groups.

Challenges and opportunities associated with the introduction of assistant practitioners supporting the work of registered nurses in NHS acute hospital trusts in England.

OBJECTIVES: To understand the challenges and opportunities associated with the introduction of assistant practitioner (AP) roles supporting the work of ward-based registered nurses (RNs) in National Health Service (NHS) acute hospital trusts in England. METHODS: Three case studies of NHS acute hospital trusts. This paper presents qualitative findings, drawing on documentary data sources and data generated through interviews and focus group discussions. RESULTS: Introduction of APs into ward-based nursing teams has been variable, and often driven by external pressures rather than perceived organizational need. This, along with little national guidance, has created some confusion about the role, but at the same time has permitted flexible role development through 'negotiated compromise' at local level. While there are various areas of potential improvement in policy and practice, APs are generally perceived to have the potential to make a valuable contribution to patient care. CONCLUSIONS: Findings from this study will help policy-makers, organizations and practitioners understand factors that enable and/or inhibit the integration of new assistant roles within existing occupational structures to develop innovative services and enhance patient care. These factors are important when considering how care will be delivered to maximize the skills of the entire nursing workforce.

The attitudes of primary schoolchildren in Northern Thailand towards their peers who are affected by HIV and AIDS.

After more than a decade of the AIDS epidemic in Thailand, the number of children whose parents are living with HIV or have died from AIDS is increasing significantly and it has been reported that these children are often discriminated against by their peers. In order to better understand the current situation and to explore possible strategies to support HIV-affected children, this study examined children's attitudes towards HIV and AIDS using questionnaires and focus group discussions with children in Grades three-six in five primary schools in a northern province in Thailand. A total of 513 children (274 boys and 239 girls) answered the questionnaire and five focus groups were organised. The findings showed a strong positive correlation between children's belief that HIV could be transmitted through casual contact and their negative attitudes towards their HIV-affected peers. Most children overestimated the risk of HIV transmission through casual contact and this made their attitudes less tolerant and less supportive. After HIV prevention education (which included information on HIV transmission routes) was given in three of the study schools, the same questionnaire and focus groups were repeated and the findings showed that children's attitudes had become more supportive. These findings suggest that HIV prevention education delivered through primary schools in Thailand can be an effective way to help foster a more supportive and inclusive environment and reduce the stigma and discrimination that decrease educational access and attainment for HIV-affected schoolchildren.

Tackling the drivers of child undernutrition in developing countries: what works and how should interventions be designed?

OBJECTIVE: The present paper presents a synthesis of available evidence to support action on the interventions that can effectively address the main drivers of child undernutrition in developing countries. It also discusses how interventions should be designed and identifies policy-relevant areas for further research. DESIGN: A structured literature review of fifty-eight controlled evaluations and studies in developing countries were selected because they are methodologically sound, recent (reported within the past 10 years), report on nutritional status, cover a wide range of interventions and are implemented by a range of different agencies. SETTING: Indirect interventions in developing countries, which address the underlying and basic causes of child undernutrition and can potentially be implemented in the short to medium term. SUBJECTS: Children under 5 years of age and their mothers across a range of developing countries. RESULTS: Evidence has now accumulated to guide action on a range of indirect interventions that can reduce child undernutrition, but for all these interventions context is all-important. There is less evidence on how these interventions can be effectively implemented on a large scale. CONCLUSIONS: Efforts should be directed towards improving implementation of effective interventions on a large scale. Donors need to keep commitments both in dollar terms and in terms of the Paris Declaration so that the push for improved nutrition does not become donor driven. At the country level, there is a need for enabling governance structures, institutions and evidence-based decision making. Within countries there is a need for well-trained personnel with delegated authority, accountable to local people. It is essential for chains of accountability to be transparent and for active involvement of households in decision-making processes.

Breaking down the wall of silence around children affected by AIDS in Thailand to support their psychosocial health.

This study examines the psychosocial needs of the children affected by AIDS. Eight primary school children aged 10-13 years who lost parents to AIDS or whose parents were living with HIV were closely followed for a period of one year and qualitative data on the psychosocial challenges they faced were collected using semi-structured interviews, observation, drawings and diaries. Data were also collected from their caregivers and classroom teachers using semi-structured interviews, as well as data from their classmates using a self-completion questionnaire. The findings strongly suggested that adults were creating a "wall of silence" around children affected by AIDS by hiding the parents' HIV status from them and avoid talking to them about HIV and AIDS. The silence was intended to protect the children from sadness, embarrassment, bullying and discrimination. In reality, however, the silence was found to have isolated them and increased their psychosocial vulnerability by blocking open communication with family members, peers and teachers, and left them to cope with their problems on their own. It is argued that to support the psychosocial health of these children, it is necessary for the adults to recognise the negative impact of silence and for the families and the school to be involved in a process of participatory learning and action to find culturally appropriate ways to break down the wall of silence, and promote more open communication.

Can regional resource shares be based only on prevalence data? An empirical investigation of the proportionality assumption.

The needs component of the current formulae for allocating resources for hospital services and prescribing in England is based on a utilisation approach. This assumes that expenditure on NHS activity in different geographical areas reflects relative needs and supply conditions, and that these can be disentangled by regression models to yield an estimate of relative need. These assumptions have been challenged on the grounds that the needs of some groups may be systematically 'unmet'. Critics have suggested an alternative based on variations in the prevalence of health conditions, called the 'epidemiological approach'. The epidemiological approach uses direct measures of morbidity to allocate health care resources. It divides the total national budget into disease programmes based on primary diagnosis, computes the proportion of total cases for each programme in each geographical area, and then allocates budgets to geographical areas proportional to their share of total cases. The main obstacle to the epidemiological approach has been seen as its very demanding data requirements. But it also faces methodological challenges. These centre on the assumption of proportionality which, at the area level to which resources will be allocated, requires that the average level of need for 'cases' within each disease programme is the same in every area. We illustrate the epidemiological approach, and test the proportionality assumption underpinning it, using data from the 2002-2004 rounds of the Health Survey for England. We find regional variation in disease severity for major diseases, which suggests that health care needs for some conditions vary by area. Further analysis suggests that the epidemiological approach might systematically underallocate resources to rural areas, areas with younger populations, and deprived areas. Since the proportionality assumption underpinning the epidemiological approach does not hold, its adoption would fail to take account of variations in severity. This casts some doubt on the utility of the approach for resource allocation at the present time.

Mapping the introduction of assistant practitioner roles in acute NHS (hospital) trusts in England.

AIMS: This mapping study describes current or planned introduction of assistant practitioner roles in English National Health Service Acute Hospital Trusts. BACKGROUND: In the last decade there has been a growth in nursing support workforce numbers and their scope of practice. An important United Kingdom support worker development is the Assistant Practitioner role. METHOD: A national census was carried out (April 2007) via an emailed questionnaire to Directors of Nursing. Quantitative data were analysed using descriptive statistics. Qualitative data were analysed using thematic analysis. RESULTS: Eighty-five per cent (143/168) of Directors of Nursing, from all 10 English Strategic Health Authorities, responded. Forty-six per cent (n = 66) of Trusts had introduced assistant practitioners and 22% (n = 31) were planning to implement the role before 2009. There is wide variation in assistant practitioner numbers across and between Strategic Health Authorities, Trusts and clinical areas. Resistance to the role existed in 32% (n = 46) of Trusts. Reasons for resistance included no perceived need for the role, lack of evidence of effectiveness, financial constraints and professional and patient safety concerns. IMPLICATIONS FOR NURSING MANAGEMENT: These findings, which contribute to the international evidence-base on health care support workers roles, provide nurse managers with numbers of assistant practitioners and their deployment. This is useful for Nurse Managers making workforce decisions.

Accuracy of child morbidity data in demographic and health surveys.

BACKGROUND: The Demographic and Health Surveys (DHSs) have been used throughout the developing world for the last 20 years to provide data on the distribution of disease in order to inform planning. Data on child illness and death are reported by mothers and are susceptible to error. METHODS: We conducted an in-depth study of the Iranian DHS carried out in 2000-2001 and reviewed 110 DHS carried out around the world to check for bias by assessing the social gradient in reported child morbidity and mortality. RESULTS: We found that the reported under-5 child morbidity and mortality rates for the 28 Iranian provinces were inversely correlated (r = -0.592, P < 0.001) and that the adjusted social gradient of child morbidity implied increased illness in those who had literate vs illiterate mothers (OR = 1.26, 95% CI 1.20-1.32) compared with a decrease in mortality with increased literacy (OR = 0.52, 95% CI 0.46-0.59). Many of the other DHSs also show increased rates of reported child diarrhoea in households with higher levels of maternal education, access to piped water and urban (vs rural) dwellings, the reverse of what is found with mortality rates. CONCLUSIONS: This suggests that there may be significant recall and reporting bias in under-5 childhood morbidity in DHSs. Caution should be used in the interpretation and use of data from DHSs and the survey methods should be reviewed.

Equity of use of inpatient services by the two communities in Northern Ireland.

OBJECTIVE: There is concern about whether public services in Northern Ireland are equitably targeted across the religious divide. This study investigates whether use of acute hospital inpatient services differs by religious denomination, after adjusting for supply and for identified demographic, morbidity and socio-economic determinants of need for such services. METHODS: Hospital utilisation at small area level was modelled against a wide range of potential health and socioeconomic factors. Spatial interactive modelling was used to estimate the effect of supply of hospital beds and other facilities on hospital utilisation. Two-stage weighted least-squares regression was used to model utilisation against need and supply. RESULTS: There was a clear positive relationship between the proportion of Roman Catholics in a ward and both need for and utilisation of inpatient services. The higher levels of relative utilisation in wards with a greater proportion of Catholics persisted after controlling for needs but not when supply variables were also entered in the regression equation. The surviving needs drivers were: uptake levels of 'income maintenance' benefits, all-ages standardised mortality ratio, low birth weight and elderly people living alone. Most of these indicators of need are positively correlated with proportion of Catholics. CONCLUSIONS: When both need and supply factors are taken into account, there appears to be no significant effect of religion on inpatient hospital use in Northern Ireland. Efforts to ensure socio-economic equity between the two communities should focus on ensuring that hospital rationalisation does not lead to disadvantage and on reducing socio-economic differentials between the Catholic and Protestant communities.

Risk adjustment for hospital use using social security data: cross sectional small area analysis.

OBJECTIVES: To identify demographic and socioeconomic determinants of need for acute hospital treatment at small area level. To establish whether there is a relation between poverty and use of inpatient services. To devise a risk adjustment formula for distributing public funds for hospital services using, as far as possible, variables that can be updated between censuses. DESIGN: Cross sectional analysis. Spatial interactive modelling was used to quantify the proximity of the population to health service facilities. Two stage weighted least squares regression was used to model use against supply of hospital and community services and a wide range of potential needs drivers including health, socioeconomic census variables, uptake of income support and family credit, and religious denomination. SETTING: Northern Ireland. MAIN OUTCOME MEASURE: Intensity of use of inpatient services. RESULTS: After endogeneity of supply and use was taken into account, a statistical model was produced that predicted use based on five variables: income support, family credit, elderly people living alone, all ages standardised mortality ratio, and low birth weight. The main effect of the formula produced is to move resources from urban to rural areas. CONCLUSIONS: This work has produced a population risk adjustment formula for acute hospital treatment in which four of the five variables can be updated annually rather than relying on census derived data. Inclusion of the social security data makes a substantial difference to the model and to the results produced by the formula.