Receiving healthcare for drug-resistant TB: a cross-sectional survey from Pakistan.

OBJECTIVE: To describe and quantify patients' self-reported experiences of receiving healthcare from Pakistan's Programmatic Management of Drug-Resistant Tuberculosis (PMDT) model of care, and to understand these experiences within the broader context of Pakistan's health system. METHOD: This was a cross-sectional survey of patients attending three PMDT clinics in Khyber-Pakhtunkhwa Province in Pakistan. RESULTS: The median consultation time at the PMDT clinics was 10 minutes. In their most recent visit to the PMDT clinic, 34.9% of patients spent >40% of their monthly income to access treatment. To specify, 71% of patients reported spending out-of-pocket for ancillary medicines and 44.7% for laboratory tests. In 10.5% of cases, medicines for drug-resistant TB (DR-TB) were dispensed without the patient attending the clinic. Only 43.7% of treatment supporters regularly accompanied patients to the clinic, and 6% supervised the patient's intake of medicines. Disbursement of financial support was irregular in 98.6% of cases. Only 6.2% of patients received their daily injections from a public facility, the rest went elsewhere. CONCLUSION: Several shortcomings in PMDT services, including hurried consultations, irregularities in financial support, and gaps in Pakistan's broader health system undermined healthcare experience of patients with DR-TB. To improve health outcomes and patients' care experience these service gaps need to be addressed.

Strengthening the response to drug-resistant TB in Pakistan: a practice theory-informed approach.

BACKGROUND: While Pakistan's Programmatic Management of Drug-Resistant Tuberculosis (PMDT) programme, launched in 2010, initially yielded significant gains in treatment outcomes, performance has since plateaued, and in some cases, regressed. OBJECTIVE: To critically investigate why the PMDT programme, well-structured and generously resourced as it is, could not improve upon or sustain this early success and to illustrate the use of practice theory as a framework to analyse functioning of health systems. METHOD: A practice theory-informed ethnographic study was conducted at three PMDT clinics. The analysis drew on 9 months of participant observation and in-depth interviews with 13 healthcare providers and four managers. RESULTS: The PMDT model primarily focused on materialities such as infrastructure, drugs and numbers of people tested, and little on developing competencies of the PMDT staff to provide responsive care. This emphasis on materialities, and the linked focus of accountability processes, led the PMDT staff to create meanings that translated into prioritisation of certain easy-to-measure health-care practices at the expense of more difficult-to-measure practices related to responsiveness that are arguably also important for successful patient outcomes. CONCLUSION: A narrow focus on measurable inputs, originating from priorities set at global and national levels, influence frontline care practices with negative consequences for quality of care and patient outcomes. Greater emphasis on improving routine process of care can enhance the effectiveness of the PMDT model of care. Practice theory provides a robust analytical framework to critically interrogate health systems and healthcare provision.

Outcomes of a brief mental health and resilience pilot intervention for young women in an urban slum in Dehradun, North India: a quasi-experimental study.

BACKGROUND: Mental illness is a leading cause of the disease burden among young people. Poor mental health is linked to childhood adversity such as gender inequality, poverty and low educational attainment. Psycho-social assets in adolescents can moderate these impacts and be strengthened. The aim of this study was to assess the effectiveness of a brief mental health and resilience intervention among disadvantaged young women in urban North India. METHODS: We used an uncontrolled repeated measures design to evaluate the effectiveness of the 15-module mental health and resilience curriculum among young women residing in a slum in Dehradun, Uttarakhand. Standardised psychometric assessments were done to assess outcomes of the intervention at three time-points: pre-intervention (T1), post-intervention (T2), and 8-months post-intervention (T3), covering domains of self-efficacy, resilience, anxiety, depression and gender attitudes. RESULTS: Young women completing the intervention (n = 106) had all left school before 10th class. A statistically significant improvement in all psychometric measures was found at T2. These improvements were sustained at T3 in the areas of anxiety, depression and gender equality attitudes, while the measures of resilience and self-efficacy had declined to baseline. CONCLUSIONS: This intervention delivered by community-based peers among highly disadvantaged young women can lead to sustained improvements in anxiety and depression and attitudes to gender equality. While other studies in LMIC have shown increased adolescent resilience through peer-led curriculums, this study demonstrates improvements in mental health and gender attitudes can endure 8-months post-intervention. This low-cost, brief intervention can improve mental health resiliency and self-efficacy among disadvantaged young people. Further research should explore how to bring sustained improvements in resilience.

Social Distance and Community Attitudes Towards People with Psycho-Social Disabilities in Uttarakhand, India.

Stigma is an important contributor to the large treatment gap for people with mental and psycho-social disabilities (PPSD) in India. Social distance as assessed by willingness to engage in relationships with PPSD is a proxy measure of stigma and potential discrimination. In North India, investigations of community attitudes towards PPSD have been limited. To describe attitudes towards people with depression and psychosis, a community sample of 960 adults in Dehradun district, India from 30 randomised clusters, was surveyed using a validated tool to assess social distance, beliefs and attitudes related to mental illness. Participants preferred greater social distance from a person with psychosis than a person with depression. Beliefs and attitudes around mental illness were diverse reflecting a wide spread of belief frameworks. After controlling for confounding, there was increased social distance among people who believed PPSD were dangerous. Factors that reduced social distance included familiarity with PPSD, and belief that PPSD can recover. Attitudes to PPSD, stigma and social distance are complex and likely to require complex responses that include promoting awareness of mental health and illness, direct contact with PPSD and increasing access to care for PPSD.

Effect of combining a health program with a microfinance-based self-help group on health behaviors and outcomes.

OBJECTIVES: Women's participation in microfinance-based self-help groups (SHGs) and the resultant social capital may provide a basis to address the gap in health attainment for poor women and their children. We investigated the effect of combining a health program designed to improve health behaviours and outcomes with a microfinance-based SHG program. DESIGN: A mixed method study was conducted among 34 villages selected from three blocks or district subdivisions of India; one in Gujarat, two in Karnataka. METHODS: A set of 17 villages representing new health program areas were pair-matched with 17 comparison villages. Two rounds of surveys were conducted with a total of 472 respondents, followed by 17 key informant interviews and 17 focus group discussions. RESULTS: Compared to a matched comparison group, women in SHGs that received the health program had higher odds of delivering their babies in an institution (OR: 5.08, 95% CI 1.21-21.35), feeding colostrum to their newborn (OR: 2.83, 95% CI 1.02-5.57), and having a toilet at home (OR: 1.53, 95% CI 0.76-3.09). However, while the change was in the expected direction, there was no statistically significant reduction in diarrhoea among children in the intervention community (OR: 0.86, 95% CI 0.42-1.76), and the hypothesis that the health program would result in decreased out-pocket expenditures on treatment was not supported. CONCLUSION: Our study found evidence that health programs implemented with microfinance-based SHGs is associated with improved health behaviours. With broad population coverage of SHGs and the social capital produced by their activities, microfinance-based SHGs may provide an avenue for addressing the health needs of poor women.

Community beliefs about treatments and outcomes of mental disorders: a mental health literacy survey in a rural area of Maharashtra, India.

OBJECTIVES: Mental health remains a neglected issue in most developing countries, especially in rural areas where access to effective mental health services is limited. The integration of mental health into primary health care is being promoted as a strategy to address this problem. Consequently, there is an urgent need to enhance mental health awareness among communities, and to provide mental health training for primary healthcare staff. In order to do this effectively, it is important to understand and take account of local views on mental health and illness. As such, a mental health literacy (MHL) assessment was undertaken in a poor, rural area of Maharashtra, India to inform the development of a mental health training programme. STUDY DESIGN: A cross-sectional MHL survey was undertaken in late 2007. METHODS: Data were collected from 240 systematically sampled community members and 60 purposively sampled village health workers (VHWs) using an interviewer-administered questionnaire. Participants were presented with two vignettes describing people experiencing symptoms of mental disorders (depression, psychosis), and were asked to name the problems, and to identify the treatments and people that were most likely to be helpful (or otherwise), and the likely outcomes for people with such problems. RESULTS: Most participants recognized that the people in the vignettes were experiencing a mental health problem. 'Depression' was the most common label for the problems experienced in the depression vignette, and 'a mind/brain problem' was the most common label in the case of the psychosis vignette. Socio-economic interventions provided by family, friends and neighbours were considered to be most helpful. Local VHWs and doctors were also viewed as potentially helpful, but psychiatrists less so. Approximately half of the sample thought that dealing with the problem alone would be helpful. Special diets, tonics, appetite stimulants and sleeping pills were also strongly endorsed, but awareness of psychiatric medications was negligible. CONCLUSION: The findings from this study highlight the need to enhance MHL in this community. Additionally, there is a need to build the capacity of the primary healthcare staff, including the VHWs, so that they are equipped to provide an effective local response for people experiencing mental health problems.

Vulnerable but feeling safe: HIV risk among male rural-to-urban migrant workers in Chengdu, China.

HIV prevalence is increasing in China. The proportion of infection attributable to heterosexual sex in China is also on the rise. The scale of internal migration for work is likely to be one of the factors contributing to these changing patterns, but little is known about HIV-related knowledge, perceptions and risk behaviours of China's migrant workers. This study aimed to investigate HIV-related knowledge, attitudes and risk behaviours of male rural-to-urban migrant workers in Chengdu and to identify factors associated with risk behaviours. In 2005, a cross-sectional questionnaire survey was completed by 163 male construction- and factory-based migrant workers aged 18-35 years. With a mean age of 26 years, just 30% had completed senior middle school and 47% were currently married. Respondents were highly mobile, worked long hours and were relatively poorly paid. As migrants, their access to urban services and benefits was restricted, making it difficult for family members to join them. Knowledge of HIV transmission was generally poor and discriminatory attitudes towards people with HIV were commonplace. Seventy-five percent were sexually experienced, among whom 88% had had sexual relations in the last 12 months. Of these, 30% had had two or more partners and 20% had paid for sex. Just 36% had used a condom during the most recent sexual encounter with a sex worker. Around 70% thought it was 'impossible' for them to become infected, yet a significant sub-group were engaging in sexual behaviours that place them at risk of infection with HIV and sexually transmitted infections (STIs). Logistic Regression found a significant association between having multiple sexual partners and both education level and marital status. Education was also found to be significantly associated with purchasing sex. Targeted HIV-prevention programs for male migrant workers in Chengdu, especially for those who are single and less educated, are urgently needed.

Injections for health-related reasons amongst injecting drug users in New Delhi and Imphal, India.

OBJECTIVES: In many parts of the world where unsafe injection practices in health settings are common, the prevalence of blood-borne viruses (BBVs) is high amongst injecting drug users (IDUs). If IDUs in these settings are receiving injections for health-related reasons, the possibility of amplification of BBV transmission via medical injections exists. The aim of this study is to describe the nature and extent of injections received for health-related reasons amongst IDUs in two Indian cities, New Delhi and Imphal. METHODS: A cross-sectional survey of 200 IDUs was conducted in late 2004. Trained peer outreach workers asked participants about health problems experienced, consultations with healthcare providers and health-related injections received in the preceding 4 weeks. RESULTS: Most participants (99.5%) were male, the average age was 29 years, and the average time since first injection of illicit drugs was 6 years. A total of 133 injections were received for health-related reasons during the preceding 4 weeks by 15% of the participants. The average number of injections was 8.6/participant/year. CONCLUSION: Injections for health-related reasons were commonplace amongst these IDUs. Therefore, amplification of BBV transmission within communities due to unsafe injections is possible and warrants further investigation.

An economic evaluation of universal infant vaccination against hepatitis B virus using a combination vaccine (Hib-HepB): a decision analytic approach to cost effectiveness.

OBJECTIVE: To evaluate the health impact and cost effectiveness of two infant vaccination strategies for protection against hepatitis B virus (HBV) infection in the Australian population. Vaccinating only high-risk infants, assuming 65% compliance, was compared with universal vaccination of infants using a combination Hib-HepB vaccine, with 87.4% compliance. METHOD: A Markov model simulated the natural history of HBV infection and disease in an Australian birth cohort. The cohort was divided into those at high risk of infection (infants born into high-risk families) and low-risk infants. Clinical and epidemiological data used were obtained from published reports and a survey of clinical experts. The model included the health costs associated with acute and chronic HBV infection, and the sequelae of chronic HBV infection. RESULTS: The model predicted that universal hepatitis B vaccination of an Australian birth cohort (260,000 births) would result in a 77% reduction in cases of HBV infection. The incremental cost per life year gained was $11,862, which is low compared with many other health care interventions. With no discounting of costs or consequences, universal vaccination with the combination vaccine was predicted to save lives and reduce costs. CONCLUSION: There is no socially accepted threshold value for cost per life year gained to guide decisions about funding Australian health care interventions. Nevertheless, based on these results, universal hepatitis B vaccination of Australian infants using a combination Hib-HepB vaccine would almost certainly be regarded as a worthwhile investment of public funds.

Health insurance status and mood during pregnancy and following birth: a longitudinal study of multiparous women.

OBJECTIVE: The objective of this study was to investigate the relationship between health insurance status and mood during pregnancy and following childbirth. METHOD: 320 women were recruited in the early stage of pregnancy to participate in a longitudinal, prospective study of the psychological aspects of childbirth among multiparous women. Study volunteers were surveyed during each trimester of pregnancy and 2 and 8 months following childbirth. A range of self-administered psychometric tests were used to assess mood (Profile of Mood State), locus of control, defence style and partner support. Demographic information including health insurance status was noted at study entry. RESULTS: Public patients consistently had a more disturbed mood compared with private patients. This difference reached statistical significance during the second and third trimesters of pregnancy and 8 months after birth. Multivariate analysis was undertaken to identify predictors of mood during pregnancy and following birth. A better mood score was positively associated with private health insurance, a more caring partner and mature defence style, and negatively associated with external locus of control and immature defence style. A distinct mood pattern during pregnancy and following childbirth was observed and is described. CONCLUSIONS: Public patients have a more disturbed mood during pregnancy and following childbirth compared with private patients. This information is relevant when planning social, psychological and psychiatric services that target childbearing women.

Tuberculosis infection and homelessness in Melbourne, Australia, 1995-1996.

OBJECTIVE: To describe tuberculosis infection among persons experiencing homelessness in inner Melbourne, Australia. DESIGN: Homeless people were surveyed during late 1995 and early 1996. In stage one of the study 284 homeless people from crisis and long-term accommodation sites were recruited by means of stratified, systematic, random sampling. In stage two a convenience sample of 100 homeless people from squats and the streets were recruited. Participants completed a questionnaire and Mantoux testing was performed. RESULTS: A past history of tuberculosis was reported by 3%. Thirty-seven per cent had a Mantoux > or =10 mm; 21% > or =15 mm; and 11% > or =20 mm. A Mantoux > or =15 mm was independently associated with being aged > or =40 years, coming from the accommodated sample, overseas birth, and a past history of tuberculosis. Using logistic regression modelling, a Mantoux > or =15 mm was predicted by being aged > or =40 years, overseas birth, and past history of tuberculosis. CONCLUSION: Mantoux test results suggest that this group of homeless people had a high prevalence of infection with the tubercle bacillus. Many aspects of the physical and social circumstances of homeless people predispose to reactivation and have the potential to enhance rapid spread should latent infection become active disease.

Health indicators and risks among people experiencing homelessness in Melbourne, 1995-1996.

During the study's first stage, 284 homeless people from crisis and long-term accommodation sites were surveyed using stratified, systematic sampling. The second stage involved a survey of a convenience sample of 100 homeless people from squats and the streets. Participants completed a questionnaire, Mantoux testing was performed and blood taken for gamma-interferon assay, liver and renal function tests. The group's health status was poor, with 72% experiencing medical conditions in the preceding two years and 77% symptoms in the month prior to interview. Bronchitis, asthma and gastroenteritis were the most commonly reported conditions; productive and persistent coughing, shortness of breath and wheezing the commonest symptoms. Twenty-one per cent had Mantoux reactions 15 mm or greater, 28% a raised GGT and 19% a raised ALT. Seventy-seven per cent smoked, 74% were current drinkers, 28% had injected drugs at some time in their lives and 14% were regularly injecting drugs. Forty-four per cent had experienced mental illness, 49% of whom reported depression and 15% schizophrenia. Homeless people in Melbourne have poor health status and engage in behaviours that place their health at risk. The high number of respiratory and gastro-intestinal complaints, the high level of cigarette smoking and injecting drug use (IDU) and the proportion likely to be infected with Mycobacterium tuberculosis (MTb) are all issues with important health consequences. Participants recruited from the street had significantly poorer health and engaged in more risk behaviours than those from accommodation sites; those from the accommodated sample were more likely to be infected with Mtb.

Patients' experiences of nursing interventions during hospitalisation with an AIDS-defining illness.

The aim of this phenomenologically informed study was to explore the experience of being hospitalised with an AIDS-defining illness. Eight men recently hospitalised with an AIDS-defining illness were asked at interview to describe the meaning of AIDS for them and the nursing interventions they experienced as helpful and unhelpful while they were in hospital. The findings pertaining to participants' experiences of nursing interventions are highlighted in this paper. Overall, the interventions experienced as helpful were those which the participants interpreted as being motivated by care. Conversely, the interventions described as unhelpful were those that suggested to the participants a lack of care on the part of nurses. The main implications of patients' experiences for nursing practice are discussed.

Physical assessment of people with AIDS.

Since the Declaration of Alma-Ata in 1978, primary health care (PHC) has been acknowledged as the most effective means of achieving "health for all". Promotion of the PHC model provides nurses with an excellent opportunity for professional growth and development. The PHC role of nurse practitioner is gradually emerging within the Australian health care system and if nurses are to fulfil this role adequately they need to equip themselves with additional skills. The art of performing competent physical assessment of clients is one such skill. As the concept of the AIDS nurse practitioner is being developed locally and overseas, this paper focuses on the physical assessment of people with AIDS. While the constellation of physical signs and symptoms they experience are all too familiar to those who work in the area, they are often unusual for those who do not.

AIDS. Nursing care.

Nursing personnel, as front-line health care providers working directly with individuals infected with HIV, their families, and their community, are presented with a challenge that requires unprecedented creativity, energy and resources. The extent to which nursing personnel are willing and able to meet this challenge may well have a profound impact on the future course of the epidemic.