Exploring community perspectives on national health insurance policy in Ghana

Even though a number of studies have examined the implementation of National Health Insurance Scheme (NHIS) in Ghana, its equity and access significance in relation to community perspective has not been assessed nationally. We looked at the NHIS from the perspective of local communities in focus groups discussions (FGDs) and key informant interviews. Qualitative data from nine key informant interviews and seventy-two community respondents in nine focus group discussions were collected. The focus groups took place in seven different communities purposely selected. The data were analysed using thematic network approach. The key informants and focus groups were analysed together. The findings noted a disconnection between NHIS policy and community life. More so, the findings showed an explicit link between equity and access with its impacts on health outcomes. The qualitative results noted lack of voice and understanding as features limiting people from accessing the NHIS facilities. Understanding of equity as a key theme revealed: first, lack of stakeholder engagement and consultation or participation in the NHIS decision making process. Second, the NHIS displayed an overreliance on healthcare and an emphasis on a biomedical approach. Finally, despite being a pro- poor intervention by name, practical management of the NHIS is transmitted down vertical silos from the national level, with the lack of joined-up government at the centre undermining local partnerships. Thus, not only are national expectations being dashed locally, local expectations are dashed nationally. We proposed that community viewpoints should be given higher priority given that NHIS has since its inception been associated with medical treatments and biomedical paradigm. Promoting community participation, understanding and voices should be recognised to shape the future NHIS policy and practice

Have Radiographic Progression Rates in Early Rheumatoid Arthritis Changed? : A Systematic Review and Meta-analysis of Long-term Cohorts

This is a pre-copyedited, author-produced version of an article accepted for publication in Rheumatology following peer review. The version of record: Lewis Carpenter, et al, ‘Have radiographic progression rates in early rheumatoid arthritis changed? A systematic review and meta-analysis of long-term cohorts’ Rheumatology, Vol. 55(6): 1053-1065, 1 June 2016, is available online at DOI: https://doi.org/10.1093/rheumatology/kew004.The objectives of this systematic review are to evaluate firstly, all published data on baseline and annual progression rates of radiographic damage from all longitudinal observational cohorts, and secondly, the association of standard clinical and laboratory parameters with long-term radiographic joint damage.MethodsA comprehensive search of the literature from 1975 to 2014, using PubMed, SCOPUS and Cochrane databases, identified a total of 28 studies that investigated long-term radiographic progression, and 41 studies investigating predictors of long-term radiographic progression. This was submitted and approved by PROSPERO in February 2014 (Registration Number: CRD42014007589).ResultsMeta-analysis indicated an overall baseline rate of 2.02%, and a yearly increase of 1.08% of maximum damage. Stratified analysis found that baseline radiographic scores did not differ significantly between cohorts recruiting patient’s pre and post 1990 (2.01% vs. 2.03%; p>0.01), however the annual rate of progression was significantly reduced in the post 1990 cohorts (0.68% vs. 1.50%; p<0.05). High levels of acute phase markers, baseline radiographic damage, anti-CCP and Rheumatoid Factor positivity remain consistently predictive of long-term radiographic joint damage. Conclusions: Critical changes in treatment practices over the last three decades are likely to explain the reduction in the long-term progression of structural joint damage. Acute phase markers and presence of Rheumatoid Factor/anti-CCP are strongly associated with increased radiographic progression.Peer reviewedFinal Accepted Versio

Mobilising Knowledge: Determining key elements for success and pitfalls in developing Community Based Tourism

Community based tourism (CBT) has often been cited as an alternative to mass tourism and an approach for tourism to become more sustainable. If developed well, CBT can become a poverty alleviation mechanism and a way to access improvements in quality of life, providing empowerment and greater economic benefit to individuals in local communities. Despite the plethora of literature on CBT and evaluation of models, there is little analysis of the facilitators and barriers to achieving it. Through the use of case studies in both academic and grey literature, this paper serves as an instructive review of the CBT literature to synthesise the key elements of success and the challenges

Basic science232. Certolizumab pegol prevents pro-inflammatory alterations in endothelial cell function

Background: Cardiovascular disease is a major comorbidity of rheumatoid arthritis (RA) and a leading cause of death. Chronic systemic inflammation involving tumour necrosis factor alpha (TNF) could contribute to endothelial activation and atherogenesis. A number of anti-TNF therapies are in current use for the treatment of RA, including certolizumab pegol (CZP), (Cimzia ®; UCB, Belgium). Anti-TNF therapy has been associated with reduced clinical cardiovascular disease risk and ameliorated vascular function in RA patients. However, the specific effects of TNF inhibitors on endothelial cell function are largely unknown. Our aim was to investigate the mechanisms underpinning CZP effects on TNF-activated human endothelial cells. Methods: Human aortic endothelial cells (HAoECs) were cultured in vitro and exposed to a) TNF alone, b) TNF plus CZP, or c) neither agent. Microarray analysis was used to examine the transcriptional profile of cells treated for 6 hrs and quantitative polymerase chain reaction (qPCR) analysed gene expression at 1, 3, 6 and 24 hrs. NF-κB localization and IκB degradation were investigated using immunocytochemistry, high content analysis and western blotting. Flow cytometry was conducted to detect microparticle release from HAoECs. Results: Transcriptional profiling revealed that while TNF alone had strong effects on endothelial gene expression, TNF and CZP in combination produced a global gene expression pattern similar to untreated control. The two most highly up-regulated genes in response to TNF treatment were adhesion molecules E-selectin and VCAM-1 (q 0.2 compared to control; p > 0.05 compared to TNF alone). The NF-κB pathway was confirmed as a downstream target of TNF-induced HAoEC activation, via nuclear translocation of NF-κB and degradation of IκB, effects which were abolished by treatment with CZP. In addition, flow cytometry detected an increased production of endothelial microparticles in TNF-activated HAoECs, which was prevented by treatment with CZP. Conclusions: We have found at a cellular level that a clinically available TNF inhibitor, CZP reduces the expression of adhesion molecule expression, and prevents TNF-induced activation of the NF-κB pathway. Furthermore, CZP prevents the production of microparticles by activated endothelial cells. This could be central to the prevention of inflammatory environments underlying these conditions and measurement of microparticles has potential as a novel prognostic marker for future cardiovascular events in this patient group. Disclosure statement: Y.A. received a research grant from UCB. I.B. received a research grant from UCB. S.H. received a research grant from UCB. All other authors have declared no conflicts of interes

Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

BackgroundAnterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.MethodsWe did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.FindingsBetween Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.InterpretationSurgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management

A labour of love: the lived experience of the parents of prisoners and their role as human rights protectors

Moving beyond the traditional focus on the children and romantic partners of prisoners, this chapter draws on in-depth interviews with Mothers and Fathers of adult children to elicit their lived experience of caring for their imprisoned child. Adopting themes identified Gueta’s 2017 global meta-synthesis, this chapter illuminates important synergies, and disparities, between the accounts of parents of prisoners in England and Wales compared to extant international literature. For many the burden of caring for their imprisoned child was profound and all-encompassing. For some this burden became even heavier as they resorted to desperate measures to protect their children from physical and psychological harm within prison walls. The chapter then goes further and locates the burden of care carried by these parents in a human rights framework. Drawing comparisons with the Salakhov and Islyamova v Ukraine (2013) human rights case, the chapter examines the previously unconsidered role parents of prisoners can play as human rights protectors for their imprisoned child and the human rights implications of the psychological harm this labour can cause parents of prisoners