Related Articles

Background

The burden of disease, disability, and mortality that could be averted by surgery is growing. However, few low and middle income countries (LMICs) have the infrastructure or capacity to provide surgical services to meet this growing need. Equally, few of these countries have been assessed for key infrastructural capacity including surgical and anesthesia providers, equipment, and supplies. These assessments are critical to revealing magnitude of the evolving surgical and anesthesia workforce crisis, related morbidity and mortality, and necessary steps to mitigate the impact of the crisis.

Methods

A pilot Internet-based survey was conducted to estimate per-capita anesthesia providers in LMICs. Information was obtained from e-mail respondents at national health care addresses, and from individuals working in-country on anesthesia-related projects.

Results

Workers from 6 of 98 countries responded to direct e-mail inquiries, and an additional five responses came from individuals who were working or had worked in-country at the time of the survey. The data collected revealed that the per-capita anesthesia provider ratio in the countries surveyed was often 100 times lower than in developed countries.

Conclusions

This pilot study revealed that the number of anesthesia providers available per capita of population is markedly reduced in low and lower middle income countries compared to developed countries. As anesthesia providers are an integral part of the delivery of safe and effective surgical care, it is essential that more data is collected to fully understand the deficiencies in workforce and capacity in low and middle income countries.

In their article, Baelani and colleagues surveyed anesthesia providers from African low- and middle-income countries (LMICs) to evaluate whether or not the current Surviving Sepsis Campaign (SSC) guidelines are feasible in such resource-constrained settings. The authors report that an alarmingly low percentage of hospitals have the capacity to implement the SSC guidelines in their entirety but a higher percentage are able to implement the majority of SSC guidelines and grade 1 recommendations. In reality, the probability of adherence to SSC guidelines for septic management is even lower than reported, given that the majority of sepsis management in African LMICs is likely performed by non-intensivists outside of intensive care units. Efforts to address the challenges of managing severely ill patients in LMICs have recently been taken on by the World Health Organization. After reviewing available evidence for sepsis management predominantly from high-income countries, a panel of experts developed a consensus-based strategy tailored for resource-limited settings. However, more research that can evaluate the challenges specific to sepsis management in LMICs and not currently addressed by the SSC guidelines is needed. Comprehensive, evidence-based guidelines combined with innovative approaches to sepsis management in LMICs are required to make a meaningful impact on worldwide sepsis survival.

Background

In resource-poor countries, such as Solomon Islands, the research agenda on health is often dominated by researchers from resource-rich countries. New strategies are needed to empower local researchers to set directions for health research. This paper presents a process which seeks to enable a local and potentially more equitable research agenda at a remote hospital in Solomon Islands.

Methods

In preparation for a health research capacity-building workshop at Atoifi Adventist Hospital, Malaita, Solomon Islands, a computer-based search was conducted of Solomon Islands public health literature. Using a levels-of-agreement approach publications were categorised as: a) original research, b) reviews, c) program descriptions and d) commentaries or discussion. Original research publications were further sub-categorised as: i) measurement, ii) descriptive research and iii) intervention studies. Results were reviewed with Solomon Islander health professionals in a focus group discussion during the health research workshop. Focus group participants were invited to discuss reactions to literature search results and how results might assist current or future local researchers to identify gaps in the published research literature and possible research opportunities at the hospital and surrounding communities. Focus group data were analysed using a grounded theory approach.

Results

Of the 218 publications meeting inclusion criteria, 144 (66%) were categorised as 'original research', 42 (19%) as 'commentaries/discussion', 28 (13%) as 'descriptions of programs' and 4 (2%) as 'reviews'. Agreement between three authors' (MRM, DM, AC) independent categorisation was 'excellent' (0.8 <κ). The 144 'original research' publications included 115 (80%) 'descriptive studies' (κ = 0.82); 19 (13%) 'intervention studies' (κ = 0.77); and 10 (7%) 'measurement studies'(κ = 0.80). Key themes identified in the focus group discussion challenged historical inequities evident from the literature review. These included: i) who has done/is doing research in Solomon Islands (largely non-Solomon Islanders); ii) when the research was done (research needs to keep up to date); iii) amount of published research (there should be more); iv) types of research (lack of intervention and operational research); v) value of published research (important); vi) gaps in published literature (need more research about nursing); vii) opportunities for research action (start small); viii) support required to undertake research at the hospital and in surrounding communities (mentoring and partnering with experienced researchers).

Conclusions

A search and collaborative review of public health literature for Solomon Islands at a health research capacity building workshop has uncovered and challenged historical inequity in the conduct and access to public health research. Emerging Solomon Islander researchers at a remote hospital are now working to set priorities and strengthen local research efforts. These efforts have highlighted the importance of collaboration and mentoring for Solomon Islanders to instigate and implement public health research to improve the health of individuals and communities served by this remote hospital.

Introduction:

Critically ill patients are common in emergency medicine, and require expert care to maximize patient outcomes. However, little data is available on the provision of critical care in the ED. The goal of this study is to describe the management of critically ill patients in the ED via a survey of Canadian emergency physicians.

Materials and Methods:

A survey of attending physician members of CAEP was conducted by email. The survey was developed by the authors and internal validity was established prior to survey deployment. Data on physician demographics, hospital resources, use of invasive procedures, vasopressor/inotropic medications, length of stay in the ED and patient responsibility were assessed.

Results:

The survey response rate was 22.9%, with the majority of respondents possessing speciality training in EM (73.5%). Respondents indicated that critically ill patients were commonly managed in the ED, with 68.5% reporting >6 critically ill patients per month, and 12.4% indicating > 20 patients per month. Respondents indicated that the majority of critically ill patients remained in the ED for 1-4 hours (70%) after resuscitation, yet 18% remained in the ED for >5 hours. Patients with a “respiratory” etiology were the most common critically ill patient population reported, followed by “cardiovascular”, “infectious” and “traumatic illness”. Direct laryngoscopy was frequently performed (66.9%> 11 in the year prior to the survey) in the year prior to the survey, while other invasive procedures and vasopressor/inotropic medications were utilized less often. EM physicians were responsible for the management of critically ill patients in the ED, even after consultation to an inpatient service, and were often required to provided acute care to critically ill patients admitted to an ICU, yet remaining in the ED prior to transfer (20% reported > 50% of the time).

Conclusion:

Our survey demonstrates that critically ill patients are common in Canadian ED's, and that EMP's are often responsible to provide care for prolonged period of time. In addition, the use of invasive procedures other then direct laryngoscopy was variable. Further research is warranted to determine the impact of delayed transfer and ED physician management of critically ill patients in the ED.

Background

The fields of surgery and trauma care have largely been neglected in the global health discussion. As a result the idea that surgery is not safe or cost effective in resource-limited settings has gone unchallenged. The SIGN Online Surgical Database (SOSD) is now one of the largest databases on trauma surgery in low- and middle-income countries (LMIC). We wished to examine infection rates and risk factors for infection after IM nail operations in LMIC using this data.

Methods

The SOSD contained 46,722 IM nail surgeries in 58 different LMIC; 46,113 IM nail operations were included for analysis.

Results

The overall follow-up rate was 23.1 %. The overall infection rate was 1.0 %, 0.7 % for humerus, 0.8 % for femur, and 1.5 % for tibia fractures. If only nails with registered follow-up (n = 10,684) were included in analyses, infection rates were 2.9 % for humerus, 3.2 % for femur, and 6.9 % for tibia fractures. Prophylactic antibiotics reduced the risk of infection by 29 %. Operations for non-union had a doubled risk of infection. Risk of infection was reduced with increasing income level of the country.

Conclusions

The overall infection rates were low, and well within acceptable levels, suggesting that it is safe to do IM nailing in low-income countries. The fact that operations for non-union have twice the risk of infection compared to primary fracture surgery further supports the use of IM nailing as the primary treatment for femur fractures in LMIC.

Background

The accuracy of malaria case reporting is challenging due to restricted human and material resources in many countries. The reporting often depends on the clinical diagnosis because of the scarcity of microscopic examinations. Particularly, clinical malaria case reporting by primary health care facilities (local clinics), which constitutes the baseline data of surveillance, has never previously been sufficiently evaluated. In order to improve the malaria reporting system to the level required to eventually eliminate this disease, this study estimates the gaps between the records of clinics and government statistics regarding the incidence of clinical malaria, and then also examines some factors that might explain the data discrepancy, including such variables as clinic staffing and record keeping.

Methods

All medical records for outpatients in 2007, handwritten by nurses, were collected from local clinics in Honiara, the capital of the Solomon Islands. The all-monthly clinical malaria cases were then recalculated. The corresponding monthly data in official statistics were provided by the government. Next, in order to estimate any data discrepancy, the ratio of the cases recorded at clinics to the cases reported to the government was determined on the monthly basis. Finally, the associations between the monthly discrepancy and other variables were evaluated by a multiple regression analysis.

Results

The mean data discrepancy between the records of clinics and government statistics was 21.2% (n = 96). Significant associations were observed between the discrepancy and the average number of patients (coefficient: 0.05, 95%CI: 0.31, 0.07), illegible handwriting (coefficient: 0.09, 95%CI: 0.04, 0.15), the use of tally sheets (coefficient:-0.38, 95%CI: -0.54, -0.22), and the clinic level (coefficient:-0.48, 95%CI:-0.89,-0.06).

Conclusion

The findings of this study demonstrate the huge data discrepancy between the records of clinics and government statistics in regard to clinical malaria case reporting. Moreover, the high numbers of patients, illegible writing, the disuse of tally sheets, and insufficient resources at some clinics are likely to be related to the increase in the discrepancy. The clinical malaria case reporting at the local clinic level therefore urgently needs improvement, in order to achieve both better malaria surveillance and to also eventually eliminate this disease in the Solomon Islands.

Until the middle of the 20th century, yaws was highly endemic and considered a serious public health problem in the Western Pacific Region (WPR), leading to intensive control efforts in the 1950s–1960s. Since then, little attention has been paid to its reemergence. Its current burden is unknown. This paper presents the results of an extensive literature review, focusing on yaws in the South Pacific. Available records suggest that the region remains largely free of yaws except for Papua New Guinea, Solomon Islands, and Vanuatu. Many clinical cases reported recently were described as “attenuated”; advanced stages are rare. A single intramuscular injection of benzathine penicillin is still effective in curing yaws. In the Pacific, yaws may be amenable to elimination if adequate resources are provided and political commitment revived. A mapping of yaws prevalence in PNG, Solomon, and Vanuatu is needed before comprehensive country-tailored strategies towards yaws elimination can be developed.

With the number of people living with dementia expected to more than double within the next 25 years, the demand for dementia home care services will increase. In this critical ethnographic study, we drew upon interview and participant data with persons with dementia, family caregivers, in-home providers, and case managers in nine dementia care networks to examine the management of dementia home care resources. Three interrelated, dialectical themes were identified: (1) finite formal care-inexhaustible familial care, (2) accessible resources rhetoric-Iinaccessible resources reality, and (3) diminishing care resources-increasing care needs. The development of policies and practices that provide available, accessible, and appropriate resources, ensuring equitable, not necessarily equal, distribution of dementia care resources is required if we are to meet the goal of aging in place now and in the future.

Background

Many countries are scaling up malaria interventions towards elimination. This transition changes demands on malaria diagnostics from diagnosing ill patients to detecting parasites in all carriers including asymptomatic infections and infections with low parasite densities. Detection methods suitable to local malaria epidemiology must be selected prior to transitioning a malaria control programme to elimination. A baseline malaria survey conducted in Temotu Province, Solomon Islands in late 2008, as the first step in a provincial malaria elimination programme, provided malaria epidemiology data and an opportunity to assess how well different diagnostic methods performed in this setting.

Methods

During the survey, 9,491 blood samples were collected and examined by microscopy for Plasmodium species and density, with a subset also examined by polymerase chain reaction (PCR) and rapid diagnostic tests (RDTs). The performances of these diagnostic methods were compared.

Results

A total of 256 samples were positive by microscopy, giving a point prevalence of 2.7%. The species distribution was 17.5% Plasmodium falciparum and 82.4% Plasmodium vivax. In this low transmission setting, only 17.8% of the P. falciparum and 2.9% of P. vivax infected subjects were febrile (≥38°C) at the time of the survey. A significant proportion of infections detected by microscopy, 40% and 65.6% for P. falciparum and P. vivax respectively, had parasite density below 100/μL. There was an age correlation for the proportion of parasite density below 100/μL for P. vivax infections, but not for P. falciparum infections. PCR detected substantially more infections than microscopy (point prevalence of 8.71%), indicating a large number of subjects had sub-microscopic parasitemia. The concordance between PCR and microscopy in detecting single species was greater for P. vivax (135/162) compared to P. falciparum (36/118). The malaria RDT detected the 12 microscopy and PCR positive P. falciparum, but failed to detect 12/13 microscopy and PCR positive P. vivax infections.

Conclusion

Asymptomatic malaria infections and infections with low and sub-microscopic parasite densities are highly prevalent in Temotu province where malaria transmission is low. This presents a challenge for elimination since the large proportion of the parasite reservoir will not be detected by standard active and passive case detection. Therefore effective mass screening and treatment campaigns will most likely need more sensitive assays such as a field deployable molecular based assay.

Objective

The primary objective was to evaluate the capacity of first-referral health facilities in Tanzania to perform basic surgical procedures. The intent was to assist in planning strategies for universal access to life-saving and disability-preventing surgical services.

Design

Cross-sectional survey.

Setting

First-referral health facilities in the United Republic of Tanzania.

Participants

48 health facilities.

Measures

The WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was employed to capture a health facility's capacity to perform basic surgical (including obstetrics and trauma) and anaesthesia interventions by investigating four categories of data: infrastructure, human resources, interventions available and equipment. The tool queried the availability of eight types of care providers, 35 surgical interventions and 67 items of equipment.

Results

The 48 facilities surveyed served 18.6 million residents (46% of the population). Supplies for basic airway management were inconsistently available. Only 42% had consistent access to oxygen, and only six functioning pulse oximeters were located in all facilities surveyed. 37.5% of facilities reported both consistent running water and electricity. While very basic interventions (suturing, wound debridement, incision and drainage) were provided in nearly all facilities, more advanced life-saving procedures including chest tube thoracostomy (30/48), open fracture management (29/48) and caesarean section delivery (32/48) were not consistently available.

Conclusions

Based on the results in this WHO country survey, significant gaps exist in the capacity for emergency and essential surgical services in Tanzania including deficits in human resources, essential equipment and infrastructure. The information in this survey will provide a foundation for evidence-based decisions in country-level policy regarding the allocation of resources and provision of emergency and essential surgical services.

Article summary

Article focus

On-site visits to primary health centres in a developing nation.

Evaluate capacity to deliver emergency and surgical care-identify gaps in equipment, skills and personnel.

Key messages

Basic surgical procedures are being performed in nearly all health centres.

Significant deficits in human resources, essential equipment and infrastructure.

Pulse oximetry is rarely available.

Strengths and limitations of this study

Most comprehensive evaluation of a developing country's surgical capacity.

Based on established well-accepted analysis tool.

Relies on subjective measures and estimate.

Background

Maternal mortality and morbidity remains high in many low- and middle-income countries (LMIC). Gestational Diabetes Mellitus (GDM) represents an underestimated and unrecognised impediment to optimal maternal health in LMIC; left untreated – it also has severe consequences for the offspring. A better understanding of the barriers hindering detection and treatment of GDM is needed. Based on experiences from World Diabetes Foundation (WDF) supported GDM projects this paper seeks to investigate societal and health system barriers to such efforts.

Methods

Questionnaires were filled out by 10 WDF supported GDM project partners implementing projects in eight different LMIC. In addition, interviews were conducted with the project partners. The interviews were analysed using content analysis.

Results

Barriers to improving maternal health related to GDM nominated by project implementers included lack of trained health care providers - especially female doctors; high staff turnover; lack of standard protocols, consumables and equipment; financing of health services and treatment; lack of or poor referral systems, feedback mechanisms and follow-up systems; distance to health facility; perceptions of female body size and weight gain/loss in relation to pregnancy; practices related to pregnant women’s diet; societal negligence of women’s health; lack of decision-making power among women regarding their own health; stigmatisation; role of women in society and expectations that the pregnant woman move to her maternal home for delivery.

Conclusions

A number of barriers within the health system and society exist. Programmes need to consider and address these barriers in order to improve GDM care and thereby maternal health in LMIC.

ABSTRACT

Purpose: The Internet may be one way to support and improve rehabilitation practice and service delivery in low- and middle-income countries (LMICs) such as Bosnia and Herzegovina. Little information exists on use of the Internet to enhance the practice and professional development of community-based rehabilitation (CBR) workers in LMICs. The purpose of this study was to assess the patterns of and barriers to Internet use by CBR workers in Bosnia and Herzegovina.

Methods: Participants were CBR workers (physiotherapists, physiatrists, and technicians) from Bosnia and Herzegovina who attended a conference or workshop in 2005. A cross-sectional questionnaire was administered in the local language to assess Internet use. Descriptive results were summarized in tables. Bivariate and multiple logistic regressions were used to assess factors associated with Internet use.

Results: A total of 33% of respondents had never used the Internet. Common barriers to Internet use included “not enough time” (24%), “no access” (23%), and “lack of skill” (18%). Participants with higher levels of education had greater odds of using the Internet than physiotherapy school graduates (odds ratio=7.6, p=0.016) and had greater odds of using the Internet to obtain medical, rehabilitation, or health information (odds ratio=5.8, p=0.028).

Conclusions: Improving CBR workers' access to the Internet and their proficiency in using it may enable them to obtain valuable rehabilitation-related information and enhance communication among CBR workers, potentially translating into improved rehabilitation services for people with disabilities in LMICs.

Background

Burden of death and disability resulting from lack of emergency medical system (EMS) and emergency care is very high in low and middle income countries (LMIC).

Aim

To study the knowledge, attitudes and practices of pre-hospital care and emergency services among health care providers of Lucknow

Setting and Design

Cross-sectional survey, 200 residents, 104 hospital consultants and 108 private practitioners

Material and Methods

A close ended, self administered questionnaire based on 5-point Likert scale with 30 items of knowledge, attitude and practice of pre-hospital and emergency care

Results

Median scores of knowledge (26/50), attitude (41/50) and practices (27/50) showed less than adequate knowledge and practices. However, a positive attitude was seen in all the 3 group of respondents i.e. resident doctors, hospital consultants and private practitioners.

Conclusion

Lucknow is the capital city of Indian largest state — Uttar Pradesh with over 100 years of established medical education. The results of the study in this town are applicable to most developed cities in India. Lack of adequate knowledge and practices in emergency medical system (EMS) at Lucknow represent a dismal situation and require continuing medical education in this area.

Introduction

Capacity building has been employed in international health and development sectors to describe the process of ‘experts’ from more resourced countries training people in less resourced countries. Hence the concept has an implicit power imbalance based on ‘expert’ knowledge. In 2011, a health research strengthening workshop was undertaken at Atoifi Adventist Hospital, Solomon Islands to further strengthen research skills of the Hospital and College of Nursing staff and East Kwaio community leaders through partnering in practical research projects. The workshop was based on participatory research frameworks underpinned by decolonising methodologies, which sought to challenge historical power imbalances and inequities. Our research question was, “Is research capacity strengthening a two-way process?”

Methods

In this qualitative study, five Solomon Islanders and five Australians each responded to four open-ended questions about their experience of the research capacity strengthening workshop and activities: five chose face to face interview, five chose to provide written responses. Written responses and interview transcripts were inductively analysed in NVivo 9.

Results

Six major themes emerged. These were: Respectful relationships; Increased knowledge and experience with research process; Participation at all stages in the research process; Contribution to public health action; Support and sustain research opportunities; and Managing challenges of capacity strengthening. All researchers identified benefits for themselves, their institution and/or community, regardless of their role or country of origin, indicating that the capacity strengthening had been a two-way process.

Conclusions

The flexible and responsive process we used to strengthen research capacity was identified as mutually beneficial. Using community-based participatory frameworks underpinned by decolonising methodologies is assisting to redress historical power imbalances and inequities and is helping to sustain the initial steps taken to establish a local research agenda at Atoifi Hospital. It is our experience that embedding mutuality throughout the research capacity strengthening process has had great benefit and may also benefit researchers from more resourced and less resourced countries wanting to partner in research capacity strengthening activities.

Background

The Australian Government's Pacific Malaria Initiative (PacMI) is supporting the National Malaria Program in both Solomon Islands and Vanuatu, complementing assistance from the Global Fund for AIDS, Tuberculosis and Malaria (GFATM). Two remote island groups - Tafea Province, Vanuatu and Temotu Province, Solomon Islands have been selected by the governments of both countries as possible malaria elimination areas. To provide information on the prevalence and distribution of the disease within these island groups, malariometric surveys were conducted during the wet seasons of 2008.

Methods

In Tafea Province, a school-based survey was conducted which included the 2-12 y age group, while in Temotu a village based all-ages survey was conducted. An effort was made to sample villages or schools from a wide an area as possible on all islands. Diagnosis was initially based on Giemsa stained blood slides followed by molecular analysis using polymerase chain reaction (PCR).

Results

In Tafea Province, 73% (5238/7150) of children (2-12 y) were surveyed and in Temotu Province, in the all-ages survey, 50.2% (8742/17410) of the provincial population participated in the survey. In both Vanuatu and Solomon Islands malariometric surveys of their southern-most islands in 2008 showed relatively low over-all malaria parasite prevalence (2 to 3%). Other features of malaria in these island groups were low parasitaemia, low gametocyte carriage rates, low spleen rates, low malaria associated morbidity, a high incidence of asymptomatic infections, and a predominance of Plasmodium vivax over Plasmodium falciparum.

Conclusion

For various reasons malaria rates are declining in these provinces providing a favourable situation for local malaria elimination. This will be advanced using mass distribution of bed nets and selective indoor residual spraying, the introduction of rapid diagnostic tests and artemisinin combination therapy, and intensive case detection and surveillance. It is as yet uncertain whether malaria parasites can themselves be sustainably eliminated from entire Melanesian islands, where they have previously been endemic. Key issues on the road to malaria elimination will be continued community involvement, improved field diagnostic methods and elimination of residual P. vivax parasites from the liver of asymptomatic persons.

Background

Many low- and middle-income countries (LMICs) lack basic surgical resources, resulting in avoidable disability and mortality. Recently, residents in surgical training programs have shown increasing interest in overseas elective experiences to assist surgical programs in LMICs. The purpose of this study was to survey Canadian surgical residents about their interest in international volunteerism.

Methods

We sent a web-based survey to all general and orthopedic surgery residents enrolled in surgical training programs in Canada. The survey assessed residents’ interests, attitudes and motivations, and perceived barriers and aids with respect to international volunteerism.

Results

In all, 361 residents completed the survey for a response rate of 38.0%. Half of the respondents indicated that the availability of an international surgery elective would have positively influenced their selection of a residency program. Excluding the 18 residents who had volunteered during residency, 63.8% of the remaining residents confirmed an interest in international volunteering with “contributing to an important cause,” “teaching” and “tourism/cultural enhancement” as the leading reasons for their interest. Perceived barriers included “lack of financial support” and “lack of available organized opportunities.” All (100%) respondents who had done an international elective during residency confirmed that they would pursue such work in the future.

Conclusion

Administrators of Canadian surgical programs should be aware of strong resident interest in global health care and accordingly develop opportunities by encouraging faculty mentorships and resources for global health teaching.

Barriers to global tuberculosis (TB) control include multidrug resistance, HIV infection, and weak health systems. Case detection is critical to TB control and is affected by all three of these. Currently, most low- and middle-income countries (LMICs) rely on direct sputum smear microscopy for diagnosis. Modern culture methods and molecular tests, previously considered too complex or too expensive for implementation in LMICs, are now being introduced there in parallel with a global effort to strengthen laboratories. It remains to be seen whether services based on these tools can be made widely accessible to patients. New point-of-care tests for TB are urgently needed but cannot be expected in the near future. In the meantime, diagnostic tools based on optimized smear microscopy, although less sensitive than reference laboratory tests, may be more accessible and have more impact on case finding. It is a matter of urgency that these improved microscopy services be integrated with services based on rapid methods that can identify multidrug-resistant cases.

Background

Geographical Reconnaissance (GR) operations using Personal Digital Assistants (PDAs) and Global Positioning Systems (GPS) have been conducted in the elimination provinces of Temotu, Solomon Islands and Tafea, Republic of Vanuatu. These operations aimed to examine modern approaches to GR to define the spatial distribution of target populations to support contemporary malaria elimination interventions.

Methods

Three GR surveys were carried out covering the outer islands of Temotu Province (October - November, 2008); Santa Cruz Island, Temotu Province (February 2009) and Tanna Island, Tafea Province (July - September 2009). Integrated PDA/GPS handheld units were used in the field to rapidly map and enumerate households, and collect associated population and household structure data to support priority elimination interventions, including bed net distribution, indoor residual spraying (IRS) and malaria case surveillance. Data were uploaded and analysed in customized Geographic Information System (GIS) databases to produce household distribution maps and generate relevant summary information pertaining to the GR operations. Following completion of field operations, group discussions were also conducted to review GR approaches and technology implemented.

Results

10,459 households were geo-referenced and mapped. A population of 43,497 and 30,663 household structures were recorded during the three GR surveys. The spatial distribution of the population was concentrated in coastal village clusters. Survey operations were completed over a combined total of 77 field days covering a total land mass area of approximately 1103.2 km2. An average of 45 households, 118 structures and a population of 184 people were recorded per handheld device per day. Geo-spatial household distribution maps were also produced immediately following the completion of GR fieldwork. An overall high acceptability of modern GR techniques and technology was observed by both field operations staff and communities.

Conclusion

GR implemented using modern techniques has provided an effective and efficient operational tool for rapidly defining the spatial distribution of target populations in designated malaria elimination zones in Solomon Islands and Vanuatu. The data generated are being used for the strategic implementation and scaling-up of priority interventions, and will be essential for establishing future surveillance using spatial decision support systems.

Background

In India, private pharmacies are ubiquitous yet critical establishments that facilitate community access to medicines. These are often the first points of treatment seeking in parts of India and other low income settings around the world. The characteristics of these pharmacies including their location, drug availability, human resources and infrastructure have not been studied before. Given the ubiquity and popularity of private pharmacies in India, such information would be useful to harness the potential of these pharmacies to deliver desirable public health outcomes, to facilitate regulation and to involve in initiatives pertaining to rational drug use. This study was a cross sectional survey that mapped private pharmacies in one district on a geographic information system and described relevant characteristics of these units.

Methods

This study of pharmacies was a part of larger cross sectional survey carried out to map all the health care providers in Ujjain district (population 1.9 million), Central India, on a geographic information system. Their location vis-à-vis formal providers of health services were studied. Other characteristics like human resources, infrastructure, clients and availability of tracer drugs were also surveyed.

Results

A total 475 private pharmacies were identified in the district. Three-quarter were in urban areas, where they were concentrated around physician practices. In rural areas, pharmacies were located along the main roads. A majority of pharmacies simultaneously retailed medicines from multiple systems of medicine. Tracer parenteral antibiotics and injectable steroids were available in 83.7% and 88.7% pharmacies respectively. The proportion of clients without prescription was 39.04%. Only 11.58% of staff had formal pharmacist qualifications. Power outages were a significant challenge.

Conclusion

This is the first mapping of pharmacies & their characteristics in India. It provides evidence of the urban dominance and close relationship between healthcare provider location and pharmacy location. The implications of this relationship are discussed. The study reports a lack of qualified staff in the presence of a high proportion of clients attending without a prescription. The study highlights the need for the better implementation of regulation. Besides facilitating regulation & partnerships, the data also provides a sampling frame for future interventional studies on these pharmacies.

Background

Given the high prevalence of depression in primary health care (PHC), the use of screening instruments has been recommended. Both brief and long depression screening instruments have been validated in low and middle income countries (LMIC), including within HIV care settings. However, it remains unknown whether the brief instruments validated in LMIC are as accurate as the long ones.

Methods

We conducted a search of PUBMED, the COCHRANE library, AIDSLINE, and PSYCH-Info from their inception up to July 2011, for studies that validated depression screening instruments in LMIC. Data were extracted into tables and analyzed using RevMan 5.0 and STATA 11.2 for the presence of heterogeneity.

Results

Nineteen studies met our inclusion criteria. The reported prevalence of depression in LMIC ranged from 11.1 to 53%. The area under curve (AUC) scores of the validated instruments ranged from 0.69-0.99. Brief as well as long screening instruments showed acceptable accuracy (AUC≥0.7). Five of the 19 instruments were validated within HIV settings. There was statistically significant heterogeneity between the studies, and hence a meta-analysis could not be conducted to completion. Heterogeneity chi-squared = 189.23 (d.f. = 18) p<.001.

Conclusion

Brief depression screening instruments in both general and HIV-PHC are as accurate as the long ones. Brief scales may have an edge over the longer instruments since they can be administered in a much shorter time. However, because the ultra brief scales do not include the whole spectrum of depression symptoms including suicide, their use should be followed by a detailed diagnostic interview.

Hadley Herbert and colleagues systematically review newborn care-seeking behaviors by caregivers in low- and middle-income countries.

Background

Despite recent achievements to reduce child mortality, neonatal deaths continue to remain high, accounting for 41% of all deaths in children under five years of age worldwide, of which over 90% occur in low- and middle-income countries (LMICs). Infections are a leading cause of death and limitations in care seeking for ill neonates contribute to high mortality rates. As estimates for care-seeking behaviors in LMICs have not been studied, this review describes care seeking for neonatal illnesses in LMICs, with particular attention to type of care sought.

Methods and Findings

We conducted a systematic literature review of studies that reported the proportion of caregivers that sought care for ill or suspected ill neonates in LMICs. The initial search yielded 784 studies, of which 22 studies described relevant data from community household surveys, facility-based surveys, and intervention trials. The majority of studies were from South Asia (n = 17/22), set in rural areas (n = 17/22), and published within the last 4 years (n = 18/22). Of the 9,098 neonates who were ill or suspected to be ill, 4,320 caregivers sought some type of care, including care from a health facility (n = 370) or provider (n = 1,813). Care seeking ranged between 10% and 100% among caregivers with a median of 59%. Care seeking from a health care provider yielded a similar range and median, while care seeking at a health care facility ranged between 1% and 100%, with a median of 20%. Care-seeking estimates were limited by the few studies conducted in urban settings and regions other than South Asia. There was a lack of consistency regarding illness, care-seeking, and care provider definitions.

Conclusions

There is a paucity of data regarding newborn care-seeking behaviors; in South Asia, care seeking is low for newborn illness, especially in terms of care sought from health care facilities and medically trained providers. There is a need for representative data to describe care-seeking patterns in different geographic regions and better understand mechanisms to enhance care seeking during this vulnerable time period.

Please see later in the article for the Editors' Summary

Editors' Summary

Background

Worldwide around 3.3 million babies die within their first month of life every year. While the global neonatal mortality rate has declined by 28% between 1990 and 2009 (from 33.2 deaths per 1,000 livebirths to 23.9), the proportion of under-five child deaths that are now in the neonatal period has increased in all regions of the world and currently stands at 41%. Of these deaths, over 90% occur in low- and middle-income countries (LMICs), making the risk of death in the neonatal period in LMICs more than six times higher than in high-income countries. In LMIC settings most babies are born at home so inappropriate and delayed care seeking can contribute substantially to neonatal mortality. Infection causes over a quarter of all deaths in neonates, but in LMICs diagnosis is often based on nonspecific clinical signs, which may delay the provision of care.

Why Was This Study Done?

In order to improve neonatal survival in LMICs, health care facilities and providers must not only be available and accessible but a baby's caregiver, often a parent or other family member, must also recognize that the baby is ill and seek help. To address this problem with effective strategies, an understanding is needed of the patterns of care-seeking behavior by babies' caregivers in seeking help from health-care facilities or providers. In this study, the researchers explored the extent and nature of care-seeking behaviors by the caregivers of ill babies in LMIC settings.

What Did the Researchers Do and Find?

Using multiple databases, the researchers conducted a comprehensive review up until October 2011 of all relevant studies including those that had not been formally published. Using specific criteria, the researchers then identified 22 appropriate studies (out of a possible 784) and recorded the same information from each study, including the number of neonates with illness or suspected illness, the number of care providers who sought care, and where care was sought. They also assessed the quality of each included study (the majority of which were from rural areas in South Asia) on the basis of a validated method for reviewing intervention effectiveness. The researchers found that the definitions of neonatal illness and care-seeking behavior varied considerably between studies or were not defined at all. Because of these inherent study differences it was not possible to statistically combine the results from the identified studies using a technique called meta-analysis, instead the researchers reported literature estimates and described their findings narratively.

The researchers' analysis included 9,098 neonates who were identified in community-based studies as being ill or suspected of being ill and a total of 4,320 related care-seeking events: care seeking ranged between 10% and 100% among caregivers including seeking care from a health facility (370) or from a health provider (1,813). Furthermore, between 4% to 100% of caregivers sought care from a trained medical provider and 4% to 48% specified receiving care at a health care facility: caregivers typically sought help from primary health care, secondary health care, and pharmacies and some from an unqualified health provider. The researchers also identified seven community-based intervention studies that included interventions such as essential newborn care, birth preparedness, and illness recognition, where all showed an increase in care seeking following the intervention.

What Do These Findings Mean?

These findings highlight the lack of a standardized and consistent approach to neonate care-seeking behaviors described in the literature. However, despite the large variations of results, care seeking for newborn illnesses in LMICs appears to be low in general and remains a key challenge to improving neonatal mortality. Global research efforts to define, understand, and address care seeking, may help to reduce the global burden of neonatal mortality. However, to achieve sustainable improvements in neonatal survival, changes are needed to both increase the demand for newborn care and strengthen health care systems to improve access to, and quality of, care. This review also shows that there is a role for interventions within the community to encourage appropriate and timely care seeking. Finally, by addressing the inconsistencies and establishing standardized terms to identify barriers to care, future studies may be able to better generalize the factors and delays that influence neonatal care seeking.

Additional Information

Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001183.

A recent PLoS Medicine study has the latest figures on neonatal mortality worldwide

UNICEF provides information about progress toward United Nations Millennium Development Goal 4

UNICEF also has information about neonatal mortality

The United Nations Population Fund has information on home births

Background

Psychosocial and mental health needs in the aftermath of conflict and disaster have attracted substantial attention. In the Solomon Islands, the conceptualisation of mental health, for several decades regarded by policy makers as primarily a health issue, has broadened and been incorporated into the national development and social policy agendas, reflecting recognition of the impact of conflict and rapid social change on the psychosocial wellbeing of the community as a whole. We sought to understand how mental health and psychosocial wellbeing were seen at the community level, the extent to which these issues were identified as being associated with periods of 'tension', violence and instability, and the availability of traditional approaches and Ministry of Health services to address these problems.

Methods

This article reports the findings of qualitative research conducted in a rural district on the island of Guadalcanal in the Solomon Islands. Key informant interviews were conducted with community leaders, and focus groups were held with women, men and young people. Wellbeing was defined broadly.

Results

Problems of common concern included excessive alcohol and marijuana use, interpersonal violence and abuse, teenage pregnancy, and lack of respect and cooperation. Troubled individuals and their families sought help for mental problems from various sources including chiefs, church leaders and traditional healers and, less often, trauma support workers, health clinic staff and police. Substance-related problems presented special challenges, as there were no traditional solutions at the individual or community level. Severe mental illness was also a challenge, with few aware that a community mental health service existed. Contrary to our expectations, conflict-related trauma was not identified as a major problem by the community who were more concerned about the economic and social sequelae of the conflict.

Conclusion

Communities identify and are responding to a wide range of mental health challenges; the health system generally can do more to learn about how this is being done, and build more comprehensive services and policy on this foundation. The findings underscore the need to promote awareness of those services which are available, to extend mental health care beyond urban centres to rural villages where the majority of the population live, and to promote community input to policy so as to ensure that it 'fits' the context.

Background

In 2009, Santa Isabel Province in the Solomon Islands embarked on a malaria elimination programme. However, very little is known in the Province about the anopheline fauna, which species are vectors, their bionomics and how they may respond to intensified intervention measures. The purpose of this study was to provide baseline data on the malaria vectors and to ascertain the possibility of successfully eliminating malaria using the existing conventional vector control measures, such as indoor residual spraying (IRS) and long-lasting insecticidal nets (LLIN).

Methods

Entomological surveys were undertaken during October 2009. To determine species composition and distribution larval surveys were conducted across on the whole island. For malaria transmission studies, adult anophelines were sampled using human landing catches from two villages - one coastal and one inland.

Results

Five Anopheles species were found on Santa Isabel: Anopheles farauti, Anopheles hinesorum, Anopheles lungae, Anopheles solomonis, and Anopheles nataliae. Anopheles hinesorum was the most widespread species. Anopheles farauti was abundant, but found only on the coast. Anopheles punctulatus and Anopheles koliensis were not found. Anopheles farauti was the only species found biting in the coastal village, it was incriminated as a vector in this study; it fed early in the night but equally so indoors and outdoors, and had a low survival rate. Anopheles solomonis was the main species biting humans in the inland village, it was extremely exophagic, with low survival rates, and readily fed on pigs.

Conclusion

The disappearance of the two major vectors, An. punctulatus and An. koliensis, from Santa Isabel and the predominance of An. hinesorum, a non-vector species may facilitate malaria elimination measures. Anopheles farauti was identified as the main coastal vector with An. solomonis as a possible inland vector. The behaviour of An. solomonis is novel as it has not been previously found biting humans in any numbers. Both species appear to be short-lived, a characteristic that will limit their transmission potential. The early night feeding behaviour and a degree of outdoor biting seen in An. farauti and particularly in An. solomonis will require that their response to IRS and LLIN be closely monitored. In coastal villages, where large, favourable breeding sites allow for high numbers of An. farauti may require the addition of larval control to achieve elimination.

Background

There is a shortage of health professionals in Pacific Island states and territories, and a need in New Zealand for Pacific health professionals to serve Pacific communities.

Methods

A cross-sectional postal survey was conducted to investigate retention of Pacific graduates. All graduates of Pacific ethnicity or nationality from the University of Otago in the years 1994 to 2004 in medicine, dentistry, pharmacy, physiotherapy and medical laboratory science were included.

Results

The response rate was 59% (75 out of 128). Only 7% of respondents were working in the Pacific Islands (12% of non-residents and 4% of New Zealand residents), though the proportion in the whole cohort could be up to 20%. One third intended to work in Pacific communities in New Zealand or the Pacific Islands in the future. Factors that would favour such an intention were an adequate income, job availability, and good working conditions.

Conclusions

Retention of graduates in the Pacific Islands is poor and measures to improve retention are needed.

Objectives

To understand the roles of nurses with advanced training in paediatrics in the Solomon Islands, and the importance of these roles to child health. To understand how adequately equipped child health nurses feel for these roles, to identify the training needs, difficulties and future opportunities.

Design

Semi-structured interviews.

Settings

Tertiary hospital, district hospitals and health clinics in the Solomon Islands.

Participants

Twenty-one paediatric nurses were interviewed out of a total of 27 in the country.

Results

All nurses were currently employed in teaching, clinical or management areas. At least one or two nurses were working in each of 7 of the 9 provinces; in the two smaller provinces there were none. Many nurses were sole practitioners in remote locations without back-up from doctors or other experienced nurses; all had additional administrative or public health duties. Different types of courses were identified: a residential diploma through the University of Papua New Guinea or New Zealand and a diploma by correspondence through the University of Sydney.

Conclusions

Child health nurses in the Solomon Islands fulfill vital clinical, public health, teaching and administrative roles. Currently they are too few in number, and this is a limiting factor for improving the quality of child health services in that country. Current methods of training require overseas travel, or are expensive, or lack relevance, or remove nurses from their work-places and families for prolonged periods of time. A local post-basic child health nursing course is urgently needed, and models exist to achieve this.