Why service users do not complain or have ‘voice’: a mixed-methods study from Nepal’s rural primary health care system

BACKGROUND: Despite abundant literature on the different aspects of health care complaint management systems in high-income countries, little is known about this area in less developed health care systems and most research to date has been conducted in hospital settings. This article seeks to address this gap by reporting on research into complaint systems in primary health care (PHC) settings in Nepal. METHODS: Using a mixed-methods design, qualitative interviews were conducted with key informants (n = 39) and six community focus groups (n = 56), in the Dang District of Nepal. In addition, interviewer-administered structured questionnaire interviews were held with 400 service users, health facility operation and management committee (HFMC) members and service providers from 22 of the 39 public health facilities. Qualitative data were transcribed, organized and then analyzed using the framework method in QSR NVivo 10, while quantitative data were analyzed using IBM SPSS 22. RESULTS: Despite service users having grievances with the health system, they did not complain frequently: 9% (n = 20) reported ever making complaints about the PHC services. Complaints made were about medicines, health facility opening hours, health facility physical environment, and service providers, and were categorized into environment/equipment, accessibility/availability, level of empathy in the care process and care/safety. Generally, complaints were made verbally to health providers or to HFMC members or female community health volunteers. Use of formal channels such as suggestion boxes or written complaints was almost non-existent. Reasons reported for not complaining included: a lack of complaint channels; lack of knowledge of service entitlements; power asymmetry between service providers and service users; lack of opportunity to choose alternative providers, lack of an established culture of complaining, and a perceived lack of responsiveness to complaints. CONCLUSION: Very few service users made complaints to PHC services in Nepal. Several contextual factors related to the community and the health system were identified as the reasons for not complaining. We recommend continuing efforts to establish proper complaints mechanisms with an increased emphasis on the existing community health system networks. Furthermore, awareness among service users about service entitlements and complaint mechanisms should be increased

Beyond good intentions: lessons on equipment donation from an African hospital.

OBJECTIVE: In 2000, a referral hospital in the Gambia accepted a donation of oxygen concentrators to help maintain oxygen supplies. The concentrators broke down and were put into storage. A case study was done to find the reasons for the problem and to draw lessons to help improve both oxygen supplies and the success of future equipment donations. METHODS: A technical assessment of the concentrators was carried out by a biomedical engineer with relevant expertise. Semi-structured interviews were undertaken with key informants, and content analysis and inductive approaches were applied to construct the history of the episode and the reasons for the failure. FINDINGS: Interviews confirmed the importance of technical problems with the equipment. They also revealed that the donation process was flawed, and that the hospital did not have the expertise to assess or maintain the equipment. Technical assessment showed that all units had the wrong voltage and frequency, leading to overheating and breakdown. Subsequently a hospital donations committee was established to oversee the donations process. On-site biomedical engineering expertise was arranged with a nongovernmental organization (NGO) partner. CONCLUSION: Appropriate donations of medical equipment, including oxygen concentrators, can be of benefit to hospitals in resource-poor settings, but recipients and donors need to actively manage donations to ensure that the donations are beneficial. Success requires planning, technical expertise and local participation. Partners with relevant skills and resources may also be needed. In 2002, WHO produced guidelines for medical equipment donations, which address problems that might be encountered. These guidelines should be publicized and used

Prospecting Period Measurements with LSST - Low Mass X-ray Binaries as a Test Case

The Large Synoptic Survey Telescope (LSST) will provide for unbiased sampling of variability properties of objects with $r$ mag $<$ 24. This should allow for those objects whose variations reveal their orbital periods ($P_{orb}$), such as low mass X-ray binaries (LMXBs) and related objects, to be examined in much greater detail and with uniform systematic sampling. However, the baseline LSST observing strategy has temporal sampling that is not optimised for such work in the Galaxy. Here we assess four candidate observing strategies for measurement of $P_{orb}$ in the range 10 minutes to 50 days. We simulate multi-filter quiescent LMXB lightcurves including ellipsoidal modulation and stochastic flaring, and then sample these using LSST's operations simulator (OpSim) over the (mag, $P_{orb}$) parameter space, and over five sightlines sampling a range of possible reddening values. The percentage of simulated parameter space with correctly returned periods ranges from $\sim$23 %, for the current baseline strategy, to $\sim$70 % for the two simulated specialist strategies. Convolving these results with a $P_{orb}$ distribution, a modelled Galactic spatial distribution and reddening maps, we conservatively estimate that the most recent version of the LSST baseline strategy will allow $P_{orb}$ determination for $\sim$18 % of the Milky Way's LMXB population, whereas strategies that do not reduce observations of the Galactic Plane can improve this dramatically to $\sim$32 %. This increase would allow characterisation of the full binary population by breaking degeneracies between suggested $P_{orb}$ distributions in the literature. Our results can be used in the ongoing assessment of the effectiveness of various potential cadencing strategies.Comment: Replacement after addressing minor corrections from the referee - mainly improvements in clarificatio

Preventive measures in infancy to reduce under-five mortality: a case-control study in The Gambia.

OBJECTIVE: To investigate the relationship between child mortality and common preventive interventions: vaccination, trained birthing attendants, tetanus toxoid during pregnancy, breastfeeding and vitamin A supplementation. METHODS: Case-control study in a population under demographic surveillance. Cases (n = 141) were children under five who died. Each was age and sex-matched to five controls (n = 705). Information was gathered by interviewing primary caregivers. RESULTS: All but one of the interventions - whether the mother had received tetanus toxoid during pregnancy - were protective against child mortality after multivariate analysis. Having a trained person assisting at child birth (OR 0.2 95% CI 0.1-0.4), receiving all vaccinations by 9 months of age (OR 0.1; 95% CI 0.01-0.3), being breastfed for more than 12 months (Children breastfed between 13 and 24 months OR 0.1 95% CI 0.03-0.3, more than 25 months OR 0.1 95% CI 0.01-0.5) and receiving vitamin A supplementation at or after 6 months of age (OR 0.05; 95% CI 0.01-0.2) were protective against child death. CONCLUSIONS: This study confirms the value of at least four available interventions in the prevention of under-five death in The Gambia. It is now important to identify those who are not receiving them and why, and to intervene to improve coverage across the population

Exploring content and psychometric validity of newly developed assessment tools for itch and skin pain in atopic dermatitis.

BackgroundAtopic dermatitis (AD) is a common skin disorder characterized by chronic inflammation, altered skin barrier function, and inflammatory cell skin infiltration that decreases health-related quality of life (HRQoL). The study objective was to understand the patient perspective of AD burden and determine suitable patient-reported outcome (PRO) measures.MethodsThis mixed methods study involved the collection of qualitative and quantitative information from adults (≥ 18 years old) and adolescents (12 - 17 years old) with clinician-confirmed AD regarding their experiences of AD symptoms and its impact on HRQoL. The first part of the study included three stages: in-person concept elicitation (CE) interviews, a 2-week daily electronic diary (eDiary) study, and in-person cognitive debriefing (CD) interviews. An Itch numeric rating scale (NRS) (v1.0) and a Skin Pain NRS (v1.0) evaluation during CD interviews required participants to think about their 'worst' itch and 'worst' skin pain in the past 24 h. Other PRO measures allowed for psychometric testing. The second part of the study involved telephone-depth interviews (TDIs) and qualitative feedback from participants who had not participated in the CD interviews. Qualitative data were thematically analyzed. Psychometric evaluation of NRS measures was performed using eDiary data.ResultsIn the CE interviews, itch and/or itching and skin pain were the most prevalent symptoms consistently discussed by participants. Both NRS measures demonstrated strong psychometric reliability and were applicable across ages with suitable concurrent validity. During the CD interviews, some participants focused their answers on their 'average' itch/itching in the past 24 h, rather than their 'worst' itch. Some participants answered the Skin Pain NRS thinking about general pain or other types of pain, rather than skin pain specifically. Consequently, modifications to both measures addressed these issues and re-tested as paper-and-pen versions in subsequent TDIs. Itch NRS (v2.0) modifications helped participants focus on their worst itching. Most participants preferred Skin Pain NRS v2.0b, which included skin pain descriptors.ConclusionsItching and skin pain are the most important and relevant AD symptoms. The Itch NRS (v2.0) and Skin Pain NRS (v2.0b) appear to be appropriate endpoints for the assessment of itching and skin pain severity for clinical trials with adults and adolescents with AD

Child Mortality after Discharge from a Health Facility following Suspected Pneumonia, Meningitis or Septicaemia in Rural Gambia: A Cohort Study.

OBJECTIVE: To measure mortality and its risk factors among children discharged from a health centre in rural Gambia. METHODS: We conducted a cohort study between 12 May 2008 and 11 May 2012. Children aged 2-59 months, admitted with suspected pneumonia, sepsis, or meningitis after presenting to primary and secondary care facilities, were followed for 180 days after discharge. We developed models associating post-discharge mortality with clinical syndrome on admission and clinical risk factors. FINDINGS: One hundred and five of 3755 (2.8%) children died, 80% within 3 months of discharge. Among children aged 2-11 and 12-59 months, there were 30 and 29 deaths per 1000 children per 180 days respectively, compared to 11 and 5 respectively in the resident population. Children with suspected pneumonia unaccompanied by clinically severe malnutrition (CSM) had the lowest risk of post-discharge mortality. Mortality increased in children with suspected meningitis or septicaemia without CSM (hazard ratio [HR] 2.6 and 2.2 respectively). The risk of mortality greatly increased with CSM on admission: CSM with suspected pneumonia (HR 8.1; 95% confidence interval (CI) 4.4 to 15), suspected sepsis (HR 18.4; 95% CI 11.3 to 30), or suspected meningitis (HR 13.7; 95% CI 4.2 to 45). Independent associations with mortality were: mid-upper arm circumference (MUAC) of 11.5-13.0 cm compared to >13.0 cm (HR 7.2; 95% CI 3.0 to 17.0), MUAC 10.5-11.4 cm (HR 24; 95% CI 9.4 to 62), and MUAC <10.5 cm (HR 44; 95% CI 18 to 108), neck stiffness (HR 10.4; 95% CI 3.1 to 34.8), non-medical discharge (HR 4.7; 95% CI 2.0 to 10.9), dry season discharge (HR 2.0; 95% CI 1.2 to 3.3), while greater haemoglobin (HR 0.82; 0.73 to 0.91), axillary temperature (HR 0.71; 95% CI 0.58 to 0.87), and oxygen saturation (HR 0.96; 95% CI 0.93 to 0.99) were associated with reduced mortality. CONCLUSION: Gambian children experience increased mortality after discharge from primary and secondary care. Interventions should target both moderately and severely malnourished children

Helioseismology with Solar Orbiter

The Solar Orbiter mission, to be launched in July 2017, will carry a suite of remote sensing and in-situ instruments, including the Polarimetric and Helioseismic Imager (PHI). PHI will deliver high-cadence images of the Sun in intensity and Doppler velocity suitable for carrying out novel helioseismic studies. The orbit of the Solar Orbiter spacecraft will reach a solar latitude of up to 21 deg (up to 34 deg by the end of the extended mission) and thus will enable the first local helioseismology studies of the polar regions. Here we consider an array of science objectives to be addressed by helioseismology within the baseline telemetry allocation (51 Gbit per orbit, current baseline) and within the science observing windows (baseline 3 x 10 days per orbit). A particularly important objective is the measurement of large-scale flows at high latitudes (rotation and meridional flow), which are largely unknown but play an important role in flux transport dynamos. The full range of Earth-Sun-spacecraft angles provided by the orbit will enable helioseismology from two vantage points by combining PHI with another instrument: stereoscopic helioseismology will allow the study of the deep solar interior and a better understanding of the physics of solar oscillations in both quiet Sun and sunspots. We have used a model of the PHI instrument to study its performance for helioseismology applications. As input we used a 6 hr time-series of realistic solar magneto-convection simulation (Stagger code) and the SPINOR radiative transfer code to synthesize the observables. The simulated power spectra of solar oscillations show that the instrument is suitable for helioseismology. In particular, the specified point spread function, image jitter, and photon noise are no obstacle to a successful mission.Comment: 35 pages, 12 figures. Accepted for publication in Space Science Review

Monitoring the introduction of pneumococcal conjugate vaccines into West Africa: design and implementation of a population-based surveillance system.

Routine use of pneumococcal conjugate vaccines (PCVs) in developing countries is expected to lead to a significant reduction in childhood deaths. However, PCVs have been associated with replacement disease with non-vaccine serotypes. We established a population-based surveillance system to document the direct and indirect impact of PCVs on the incidence of invasive pneumococcal disease (IPD) and radiological pneumonia in those aged 2 months and older in The Gambia, and to monitor changes in serotype-specific IPD. Here we describe how this surveillance system was set up and is being operated as a partnership between the Medical Research Council Unit and the Gambian Government. This surveillance system is expected to provide crucial information for immunisation policy and serves as a potential model for those introducing routine PCV vaccination in diverse settings

Salen Mn Complexes Mitigate Radiation Injury in Normal Tissues

Salen Mn complexes, including EUK-134, EUK-189 and a newer cyclized analog EUK-207, are synthetic SOD/catalase mimetics that have beneficial effects in many models of oxidative stress. As oxidative stress is implicated in some forms of delayed radiation injury, we are investigating whether these compounds can mitigate injury to normal tissues caused by ionizing radiation. This review describes some of this research, focusing on several tissues of therapeutic interest, namely kidney, lung, skin, and oral mucosa. These studies have demonstrated suppression of delayed radiation injury in animals treated with EUK-189 and/or EUK-207. While an antioxidant mechanism of action is postulated, it is likely that the mechanisms of radiation mitigation by these compounds in vivo are complex and may differ in the various target tissues. Indicators of oxidative stress are increased in lung and skin radiation injury models, and suppressed by salen Mn complexes. The role of oxidative stress in the renal injury model is unclear, though EUK-207 does mitigate. In certain experimental models, salen Mn complexes have shown “mito-protective” properties, that is, attenuating mitochondrial injury. Consistent with this, EUK-134 suppresses effects of ionizing radiation on mitochondrial function in rat astrocyte cultures. In summary, salen Mn complexes could be useful to mitigate delayed radiation injury to normal tissues following radiation therapy, accidental exposure, or radiological terrorism. Optimization of their mode of delivery and other key pharmaceutical properties, and increasing understanding of their mechanism(s) of action as radiation mitigators, are key issues for future study