Determinants of trends in neonatal, post-neonatal, infant, child and under-five mortalities in Tanzania from 2004 to 2016

Background: Under-five mortality is still a major health issue in many developing countries like Tanzania. To achieve the Sustainable Development Goal target of ending preventable child deaths in Tanzania, a detailed understanding of the risk factors for under-five deaths is essential to guide targeted interventions. This study aimed to investigate trends and determinants of neonatal, post-neonatal, infant, child and under-five mortalities in Tanzania from 2004 to 2016. Methods: The study used combined data from the 2004–2005, 2010 and 2015–2016 Tanzania Demographic and Health Surveys, with a sample of 25,951 singletons live births and 1585 under-five deaths. We calculated age-specific mortality rates, followed by an assessment of trends and determinants (community, socioeconomic, individual and health service) of neonatal, postneonatal, infant, child and under-five mortalities in Cox regression models. The models adjusted for potential confounders, clustering and sampling weights. Results: Between 2004 and 2016, we found that neonatal mortality rate remained unchanged, while postneonatal mortality and child mortality rates have halved in Tanzania. Infant mortality and under-five mortality rates have also declined. Mothers who gave births through caesarean section, younger mothers (< 20 years), mothers who perceived their babies to be small or very small and those with fourth or higher birth rank and a short preceding birth interval (≤2 years) reported higher risk of neonatal, postneonatal and infant mortalities. Conclusion: Our study suggests that there was increased survival of children under-5 years in Tanzania driven by significant improvements in postneonatal, infant and child survival rates. However, there remains unfinished work in ending preventable child deaths in Tanzania

Pathways to diagnosis of non-small cell lung cancer : a descriptive cohort study

Little has been published on the diagnostic and referral pathway for lung cancer in Australia. This study set out to quantify general practitioner (GP) and lung specialist attendance and diagnostic imaging in the lead-up to a diagnosis of non-small cell lung cancer (NSCLC) and identify common pathways to diagnosis in New South Wales (NSW), Australia. We used linked health data for participants of the 45 and Up Study (a NSW population-based cohort study) diagnosed with NSCLC between 2006 and 2012. Our main outcome measures were GP and specialist attendances, X-rays and computed tomography (CT) scans of the chest and lung cancer-related hospital admissions. Among our study cohort (N = 894), 60% (n = 536) had ≥4 GP attendances in the 3 months prior to diagnosis of NSCLC, 56% (n = 505) had GP-ordered imaging (chest X-ray or CT scan), 39% (N = 349) attended a respiratory physician and 11% (N = 102) attended a cardiothoracic surgeon. The two most common pathways to diagnosis, accounting for one in three people, included GP and lung specialist (respiratory physician or cardiothoracic surgeon) involvement. Overall, 25% of people (n = 223) had an emergency hospital admission. For 14% of people (N = 129), an emergency hospital admission was the only event identified on the pathway to diagnosis. We found little effect of remoteness of residence on access to services. This study identified a substantial proportion of people with NSCLC being diagnosed in an emergency setting. Further research is needed to establish whether there were barriers to the timely diagnosis of these cases

Through a screen, darkly : how do patient-initiated camera phone images contribute to general practice consultations?

Aims & rationale/Objectives: Patients are spontaneously beginning to show photos and video recorded on mobile phones during GP consultations. Case reports describe how such images assist with diagnosis, but little is known about how camera phone images contribute to, or detract from, patient-centred care. This study aims to explore GP perceptions of patient-generated camera phone images. Methods: Semi-structured telephone interviews with nine GPs from three States with a variety of clinical interests. Interviews were recorded, transcribed and common themes identified inductively. Principal findings: GPs describe two categories of images - clinical and social. They cited examples of clinical images assisting with diagnosis, but also recognised that taking and sharing images via their phones empowered patients. Patients became part of the health care team, maintaining control over images that they use as a pictorial medical record to show different doctors. In addition, the act of sharing social images can improve rapport as it is done within a trusting relationship. The otherwise unspoken story behind the image enhances the GP's understanding of the patient and their illness. GPs have also experienced patients inappropriately using camera phones during the consultation, and expressed concerns about documenting images shown to them. Implications: GPs privileged to be shown camera phone images are given insight into spaces in patients' lives outside the consulting room. Images may hold unspoken meaning, and enhance doctor-patient relationships. Potential, but avoidable, harms were identified in this study

Patient-initiated camera phone images in general practice : a qualitative study of illustrated narratives

Background: Camera phones have become ubiquitous in the digital age. Patients are beginning to bring images recorded on their mobile phones to share with their GP during medical consultations. Aim: To explore GP perceptions about the effect of patient-initiated camera phone images on the consultation. Design and setting: An interview study of GPs based in rural and urban locations in Australia. Methods: Semi-structured telephone interviews with nine GPs about their experiences with patient-initiated camera phone images. Results: GPs described how patient-initiated camera phone photos and videos contributed to the diagnostic process, management and continuity of care. These images gave GPs in the study additional insight into the patient's world. Potential harm resulting from inappropriate use of camera phones by patients was also identified. Conclusion: Patient-initiated camera phone images can empower patients by illustrating their narratives, thus contributing to improved communication in general practice. Potential harm could result from inappropriate use of these images. GPs shown images on patients' camera phones should make the most of this opportunity for improved understanding of the patient's world. There are however, potential medicolegal implications such as informed consent, protection of patient and doctor privacy, and the risk of misdiagnosis

Found in translation : navigating uncertainty to save a child's heart : paediatric cardiac surgery in Cape Town, South Africa

This medical humanities paper describes our qualitative research into pathways to care and informed consent for 10 children who had cardiac surgery in the Red Cross War Memorial Children’s Hospital, Cape Town, South Africa. Our multidisciplinary team consists of cardiologists, anthropologists, a social scientist and a general practitioner in two sites, South Africa and Australia. This paper builds on our first publication in a specialist cardiology journal on a ‘qualitative snapshot’ of these children’s life stories from 2011 to 2016 but turns to the medical humanities to explore a concept of ‘uncertainty’. Data analysis revealed that for the children’s parents and doctors, ‘uncertainty’ underscored procedures. Indeed, the literature review showed that ‘uncertainty’ is intrinsic to heart surgery and was integral to Barnard’s first heart transplant in Cape Town in 1967. We demonstrate that in meeting the challenges inherent in the ‘uncertainty dimension’, doctors established greater ‘medical certainty’about each operation. This happened as they encountered the difficult clinical and biopsychosocial factors that were fundamental to the diagnosis of children’s cardiac defects. It was doctors’ translation of these decision-making processes that informed parental decisions and described why, despite feelings of uncertainty, parents signed consent. To visually describe heart surgery in this locality we asked the South African photographer, Guy Neveling to record some children undergoing echocardiograms and surgery. These photographs qualitatively demonstrate what medical certainty entails, and parents’ trust in doctors and surgeons, whom they knew had ‘reasonable certainty’ that their child’s ‘heart is worth saving’

Do patients from culturally diverse communities in Sydney have differing knowledge, beliefs and expectations about antibiotic use for respiratory infections?

Patient expectations can influence how general practitioners (GP) prescribe antibiotics. Overseas studies demonstrate a relationship between ethnicity and antibiotic usage. Little is known about whether patients from culturally and linguistically diverse (CALD) backgrounds in Australia have differing knowledge, beliefs and expectations about antibiotic usage

Linguistically diverse general practice teaching

Background: Learning about general practice in a context of linguistic diversity is an understudied area. There may be additional learning needs or unrecognised opportunities in this environment. This study explores the experiences of general practitioners (GPs) and medical students on placement where consultations are conducted in a language other than English (LOTE). Method: We conducted 19 semi‐structured interviews with medical students and GP supervisors who consult in LOTE. We explored experiences of learning, and teaching strategies implemented by GP supervisors. Thematic analysis was undertaken. Results: Participants reported that LOTE consultations provided unique learning opportunities, including use of interpreters and development of cross‐cultural communication skills. Facilitators to learning included the GP engaging the student in the consultation by interpreting, and patients being open to student participation. Some students described language as a barrier to learning, where they had difficulty in following the consultation. Time required for interpreting limited interaction and learning in GP consultations. We identified ways to navigate the language barrier; including the GP acting as interpreter, and students learning key phrases in the consultation language to build rapport. Discussion: Learning in the linguistically diverse General Practice environment can be optimised through an active and collaborative approach between the GP, student, and patients. Our findings highlight specific barriers and facilitators to learning. Our participants identified a variety of techniques, including skills in interpreter use and cross‐cultural communication skills which can transcend language barriers, to create valuable opportunities for medical students to learn in this setting

Linguistically diverse general practice teaching

Background: Learning about general practice in a context of linguistic diversity is an understudied area. There may be additional learning needs or unrecognised opportunities in this environment. This study explores the experiences of general practitioners (GPs) and medical students on placement where consultations are conducted in a language other than English (LOTE). Method: We conducted 19 semi‐structured interviews with medical students and GP supervisors who consult in LOTE. We explored experiences of learning, and teaching strategies implemented by GP supervisors. Thematic analysis was undertaken. Results: Participants reported that LOTE consultations provided unique learning opportunities, including use of interpreters and development of cross‐cultural communication skills. Facilitators to learning included the GP engaging the student in the consultation by interpreting, and patients being open to student participation. Some students described language as a barrier to learning, where they had difficulty in following the consultation. Time required for interpreting limited interaction and learning in GP consultations. We identified ways to navigate the language barrier; including the GP acting as interpreter, and students learning key phrases in the consultation language to build rapport. Discussion: Learning in the linguistically diverse General Practice environment can be optimised through an active and collaborative approach between the GP, student, and patients. Our findings highlight specific barriers and facilitators to learning. Our participants identified a variety of techniques, including skills in interpreter use and cross‐cultural communication skills which can transcend language barriers, to create valuable opportunities for medical students to learn in this setting

One medical school's experience of sustaining general practice teaching in the time of COVID-19

THE COVID-19 PANDEMIC is affecting health and education systems internationally.1 Maintaining health workforce capacity, including continuity of medical student training, has been a focus of efforts in Australia and globally.2 This brief article documents challenges encountered in maintaining the Western Sydney University (WSU) general practice program and strategies adopted to address these challenges