QuantiFERON®-TB gold in-tube performance for diagnosing active tuberculosis in children and adults in a high burden setting.

To determine whether QuantiFERON®-TB Gold In-Tube (QFT) can contribute to the diagnosis of active tuberculosis (TB) in children in a high-burden setting and to assess the performance of QFT and tuberculin skin test (TST) in a prospective cohort of TB suspect children compared to adults with confirmed TB in Tanzania. Sensitivity and specificity of QFT and TST for diagnosing active TB as well as indeterminate QFT rates and IFN-γ levels were assessed in 211 TB suspect children in a Tanzanian district hospital and contrasted in 90 adults with confirmed pulmonary TB. Sensitivity of QFT and TST in children with confirmed TB was 19% (5/27) and 6% (2/31) respectively. In adults sensitivity of QFT and TST was 84% (73/87) and 85% (63/74). The QFT indeterminate rate in children and adults was 27% and 3%. Median levels of IFN-γ were lower in children than adults, particularly children <2 years and HIV infected. An indeterminate result was associated with age <2 years but not malnutrition or HIV status. Overall childhood mortality was 19% and associated with an indeterminate QFT result at baseline. QFT and TST showed poor performance and a surprisingly low sensitivity in children. In contrast the performance in Tanzanian adults was good and comparable to performance in high-income countries. Indeterminate results in children were associated with young age and increased mortality. Neither test can be recommended for diagnosing active TB in children with immature or impaired immunity in a high-burden setting

The use of biomedicine, complementary and alternative medicine, and ethnomedicine for the treatment of epilepsy among people of South Asian origin in the UK

Studies have shown that a significant proportion of people with epilepsy use complementary and alternative medicine (CAM). CAM use is known to vary between different ethnic groups and cultural contexts; however, little attention has been devoted to inter-ethnic differences within the UK population. We studied the use of biomedicine, complementary and alternative medicine, and ethnomedicine in a sample of people with epilepsy of South Asian origin living in the north of England. Interviews were conducted with 30 people of South Asian origin and 16 carers drawn from a sampling frame of patients over 18 years old with epilepsy, compiled from epilepsy registers and hospital databases. All interviews were tape-recorded, translated if required and transcribed. A framework approach was adopted to analyse the data. All those interviewed were taking conventional anti-epileptic drugs. Most had also sought help from traditional South Asian practitioners, but only two people had tried conventional CAM. Decisions to consult a traditional healer were taken by families rather than by individuals with epilepsy. Those who made the decision to consult a traditional healer were usually older family members and their motivations and perceptions of safety and efficacy often differed from those of the recipients of the treatment. No-one had discussed the use of traditional therapies with their doctor. The patterns observed in the UK mirrored those reported among people with epilepsy in India and Pakistan. The health care-seeking behaviour of study participants, although mainly confined within the ethnomedicine sector, shared much in common with that of people who use global CAM. The appeal of traditional therapies lay in their religious and moral legitimacy within the South Asian community, especially to the older generation who were disproportionately influential in the determination of treatment choices. As a second generation made up of people of Pakistani origin born in the UK reach the age when they are the influential decision makers in their families, resort to traditional therapies may decline. People had long experience of navigating plural systems of health care and avoided potential conflict by maintaining strict separation between different sectors. Health care practitioners need to approach these issues with sensitivity and to regard traditional healers as potential allies, rather than competitors or quacks

Family stories, public silence: Irish identity construction amongst the second-generation Irish in England

Formal narratives of history, especially that of colonial oppression, have been central to the construction of national identities in Ireland. But the Irish diasporic community in Britain has been cut off from the reproduction of these narratives, most notably by their absence from the curriculum of Catholic schools, as result of the unofficial 'denationalisation' pact agreed by the Church in the 19th century (Hickman, 1995). The reproduction of Irish identities is largely a private matter, carried out within the home through family accounts of local connections, often reinforced by extended visits to parent/s 'home' areas. Recapturing a public dimension has often become a personal quest in adulthood, 'filling in the gaps'. This paper explores constructions of narratives of nation by a key diasporic population, those with one or two Irish-born parents. It places particular emphasis on varying regional/national contexts within which such constructions take place, drawing on focus group discussions and interviews for the ESRC-funded Irish 2 Project in five locations — London, Glasgow, Manchester, Coventry and Banbury

"They don't care what happens to us." The situation of double orphans heading households in Rakai District, Uganda

<p>Abstract</p> <p>Background</p> <p>This article is based on information collected about the situation of double orphans who are heading households in Rakai District, Uganda. The information will be used as justification and guidance for planning actions to improve the situation of these and similar children. This research is thus the first step in an Action Research approach leading to specific interventions. The aim of this article is to describe the situation of these orphaned children, with an emphasis on the psychosocial challenges they face.</p> <p>Methods</p> <p>The study involved interviews, focus group discussions, observations and narratives. Forty-three heads of sibling-headed households participated. Information derived from informal discussions with local leaders is also included. The responses were analyzed using a modified version of Giorgi's psychological phenomenological method as described by Malterud <abbrgrp><abbr bid="B1">1</abbr></abbrgrp>.</p> <p>Results</p> <p>Factors such as lack of material resources, including food and clothes, limited possibilities to attend school on a regular basis, vast responsibilities and reduced possibilities for social interaction all contribute to causing worries and challenges for the child heads of households. Most of the children claimed that they were stigmatized and, to a great extent, ignored and excluded from their community. The Local Council Secretary ("Chairman") seemed to be the person in the community most responsible and helpful, but some chairmen seemed not to care at all. The children requested counseling for themselves as well as for community members because they experienced lack of understanding from other children and from adult community members.</p> <p>Conclusion</p> <p>The children experienced their situation as a huge and complex problem for themselves as well as for people in their villages. However, the situation might improve if actions focused on practical and psychological issues as well as on sensitization about the children's situation could be initiated. In addition to the fact that these children need adult guidance to become citizens who act in accordance with the expectations in their communities, material aid is important in order to reduce the children's experiences of being "different" and constantly experiencing survival anxieties.</p> <p indent="1"><it>Before my parents died, I was schooling without facing any problems and my heart was at rest. When they died I went to live with Jjajja [grandmother]. She fell very sick and I came out of school for a full term to look after her. I was treating Jjajja but she was not getting better. She died...so...I got my schoolmates' books and copied notes that they had taken while I was away from school...I face the problem of not having good friends. Some see me as a disease...other people are not bad. Some call me names and say that I am stupid, that I probably inherited the stupidity from my mother or father...Ever since my parents died, I have not had peace. I spend most of the time thinking, crying and struggling within myself asking God why He really had to do such a thing and saying to myself that: "God, help me overcome these problems!"</it></p> <p indent="1"><it>Girl, 15</it>.</p

Constraints and prospects for contraceptive service provision to young people in Uganda: providers' perspectives

<p>Abstract</p> <p>Background</p> <p>Unintended pregnancies lead to unsafe abortions, which are a leading cause of preventable maternal mortality among young women in Uganda. There is a discrepancy between the desire to prevent pregnancy and actual contraceptive use. Health care providers' perspectives on factors influencing contraceptive use and service provision to young people aged 15-24 in two rural districts in Uganda were explored.</p> <p>Methods</p> <p>Semi-structured questionnaires were used for face- to-face interviews with 102 providers of contraceptive service at public, private not-for-profit, and private for-profit health facilities in two rural districts in Uganda. Descriptive and inferential statistics were used in the analysis of data.</p> <p>Results</p> <p>Providers identified service delivery, provider-focused, structural, and client-specific factors that influence contraceptive use among young people. Contraceptive use and provision to young people were constrained by sporadic contraceptive stocks, poor service organization, and the limited number of trained personnel, high costs, and unfriendly service. Most providers were not competent enough to provide long-acting methods. There were significant differences in providers' self-rated competence by facility type; private for-profit providers' competence was limited for most contraceptives. Providers had misconceptions about contraceptives, they had negative attitudes towards the provision of contraceptives to young people, and they imposed non-evidence-based age restrictions and consent requirements. Thus, most providers were not prepared or were hesitant to give young people contraceptives. Short-acting methods were, however, considered acceptable for young married women and those with children.</p> <p>Conclusion</p> <p>Provider, client, and health system factors restricted contraceptive provision and use for young people. Their contraceptive use prospects are dependent on provider behavior and health system improvements.</p

Determinants of facility delivery after implementation of safer mother programme in Nepal: A prospective cohort study

Background: There are several barriers for pregnant women to deliver in a health care facility. This prospective cohort study investigated factors affecting facility delivery and reasons for unplanned place of delivery after implementation of the safer mother programme in Nepal. Methods: Baseline interviews using a validated questionnaire were conducted on a sample of 700 pregnant women representative of the Kaski district in central Nepal. Follow-up interviews of the cohort were then conducted within 45 days postpartum. Stepwise logistic regression analysis was performed to determine factors associated with the facility delivery outcome. Results: Of the 644 pregnant women whose delivery location had been identified, 547 (85%) gave birth in a health care facility. Women were more likely to deliver in a health facility if they were educated especially with higher secondary or above qualification (adjusted odds ratio (OR) 12.39, 95% confidence interval (CI) 5.09 to 30.17), attended 4 or more antenatal care visits (OR 2.15, 95% CI 1.25 to 3.69), and lived within 30 minutes to the facility (OR 11.61, 95% CI 5.77 to 24.04). For the 97 women who delivered at home, 72 (74.2%) were unplanned, mainly due to quick precipitation of labour making it impossible to reach a health facility. Conclusions: It appeared that facility delivery occurs more frequent among educated women and those who live nearby, even though maternity services are now freely available in Nepal. Because of the difficult terrain and transportation problem in rural areas, interventions that make maternity service physically accessible during antenatal period are needed to increase the utilisation of health facility for child birth

Accuracy of prognosis estimates by four palliative care teams: a prospective cohort study

BACKGROUND: Prognosis estimates are used to access services, but are often inaccurate. This study aimed to determine the accuracy of giving a prognosis range. METHODS AND MEASUREMENTS: A prospective cohort study in four multi-professional palliative care teams in England collected data on 275 consecutive cancer referrals who died. Prognosis estimates (minimum – maximum) at referral, patient characteristics, were recorded by staff, and later compared with actual survival. RESULTS: Minimum survival estimates ranged <1 to 364 days, maximum 7 – 686 days. Mean patient survival was 71 days (range 1 – 734). In 42% the estimate was accurate, in 36% it was over optimistic and in 22% over pessimistic. When the minimum estimate was less than 14 days accuracy increased to 70%. Accuracy was related, in multivariate analysis, to palliative care team and (of borderline significance) patient age. CONCLUSIONS: Offering a prognosis range has higher levels of accuracy (about double) than traditional estimates, but is still very often inaccurate, except very close to death. Where possible clinicians should discuss scenarios with patients, rather than giving a prognosis range

Women’s Perception of Quality of Maternity Services: A Longitudinal Survey in Nepal

Background: In the context of maternity service, the mother’s assessment of quality is central because emotional, cultural and respectful supports are vital during labour and the delivery process. This study compared client-perceived quality of maternity services between birth centres, public and private hospitals in a central hills district of Nepal. Methods: A cohort of 701 pregnant women of 5 months or more gestational age were recruited and interviewed, followed by another interview within 45 days of delivery. Perception of quality was measured by a 20-item scale with three sub-scales: health facility, health care delivery, and interpersonal aspects. Perceived quality scores were analysed by ANOVA with post-hoc comparisons and multiple linear regression.Results: Within the health facility sub-scale, birth centre was rated lowest on items ‘adequacy of medical equipment’, ‘health staff suited to women’s health’ and ‘adequacy of health staff’, whereas public hospital was rated the lowest with respect to ‘adequacy of room’, ‘adequacy of water’, ‘environment clean’, ‘privacy’ and ‘adequacy of information’. Mean scores of total quality and sub-scales health facility and health care delivery for women attending private hospital were higher (p < 0.001) than those using birth centre or public hospital. Mean score of the sub-scale interpersonal aspects for public hospital users was lower (p < 0.001) than those delivered at private hospital and birth centre. However, perception on interpersonal aspects by women using public hospital improved significantly after delivery (p< 0.001). Conclusions: Overall, perception of quality differed significantly by types of health facility used for delivery. They rated lowest the supplies and equipment in birth centres and the amenities and interpersonal aspects in the public hospital. Accordingly, attention to these aspects is needed to improve the quality

Review of small rural health services in Victoria: how does the nursing-medical division of labour affect access to emergency care?

Aims This paper is based on a review of the Australian and International literature relating to the nursing-medical division of labour. It also explores how the division of labour affects patient access to emergency care in small rural health services in Victoria, Australia. Background The paper describes the future Australian health workforce and the implications for rural Victoria. The concept of division of labour and how it relates to nursing and medicine is critically reviewed. Two forms of division of labour emerge – traditional and negotiated division of labour. Key themes are drawn from the literature that describes the impact of a traditional form of division of labour in a rural context. Methods This paper is based on a review of the Australian and international literature, including grey literature, on the subject of rural emergency services, professional boundaries and roles, division of labour, professional relationships and power and the Australian health workforce. Results In Australia, the contracting workforce means that traditional divisions of labour between health professionals cannot be sustained without reducing access to emergency care in rural Victoria. A traditional division of labour results in rural health services that are vulnerable to slight shifts in the medical workforce, unsafe services and recruitment and retention problems. A negotiated form of division of labour provides a practical alternative. Conclusion A division of labour that is negotiated between doctors and nurses and supported by a legal and clinical governance framework, is needed to support rural emergency services. The published evidence suggests that this situation currently does not exist in Victoria. Strategies are offered for creating and supporting a negotiated division of labour