Evaluating Niger's experience in strengthening supervision, improving availability of child survival drugs through cost recovery, and initiating training for Integrated Management of Childhood Illness (IMCI)

BACKGROUND: WHO and UNICEF have recently developed the "Integrated Management of Childhood Illness" (IMCI) as an efficient strategy to assist developing countries reduce childhood mortality. Early experience with IMCI implementation suggests that clinical training is essential but not sufficient for the success of the strategy. Attention needs to be given to strengthening health systems, such as supervision and drug supply. RESULTS: This paper presents results of evaluating an innovative approach for implementing IMCI in Niger. It starts with strengthening district level supervision and improving the availability of child survival drugs through cost recovery well before the beginning of IMCI clinical training. The evaluation documented the effectiveness of the initial IMCI clinical training and referral. CONCLUSIONS: Strengthening supervision and assuring the availability of essential drugs need to precede the initiation of IMCI Clinical training. Longer term follow up is necessary to confirm the impact of the approach on IMCI preparation and implementation

Perspectives on Intergenerational Vulnerability for Adolescents Affected by HIV: An Argument for Voice and Visibility

The authors address the dynamic role of adolescents affected by HIV and AIDS. They analyse evidence for how intergenerational dynamics interact with HIV?related vulnerability, through the likely influence of being AIDS?affected on vulnerability to HIV infection, and through intergenerational reproductions of structural disadvantages and social determinants of HIV vulnerability. They review evidence of AIDS' impacts on children and of contextual influences on their vulnerability to infection, linked to orphaning, inequality and lack of education. They point to the paucity of longitudinal research into this area and challenges in uncovering structural determinants of vulnerability. Pressure for generalised ‘hard’ evidence in global policy fails to capture context?specific dynamics. Focus shifts from the notion of children as passive ‘objects’ of study to one that includes ‘agency’ as central to adolescents maturing and interacting with multiple challenges. The authors argue for new approaches to research and policy, giving children voice and visibility in these debates

Use of RDTs to improve malaria diagnosis and fever case management at primary health care facilities in Uganda

<p>Abstract</p> <p>Background</p> <p>Early and accurate diagnosis of malaria followed by prompt treatment reduces the risk of severe disease in malaria endemic regions. Presumptive treatment of malaria is widely practised where microscopy or rapid diagnostic tests (RDTs) are not readily available. With the introduction of artemisinin-based combination therapy (ACT) for treatment of malaria in many low-resource settings, there is need to target treatment to patients with parasitologically confirmed malaria in order to improve quality of care, reduce over consumption of anti-malarials, reduce drug pressure and in turn delay development and spread of drug resistance. This study evaluated the effect of malaria RDTs on health workers' anti-malarial drug (AMD) prescriptions among outpatients at low level health care facilities (LLHCF) within different malaria epidemiological settings in Uganda.</p> <p>Methods</p> <p>All health workers (HWs) in 21 selected intervention (where RDTs were deployed) LLHF were invited for training on the use RDTs. All HWs were trained to use RDTs for parasitological diagnosis of all suspected malaria cases irrespective of age. Five LLHCFs with clinical diagnosis (CD only) were included for comparison. Subsequently AMD prescriptions were compared using both a 'pre - post' and 'intervention - control' analysis designs. In-depth interviews of the HWs were conducted to explore any factors that influence AMD prescription practices.</p> <p>Results</p> <p>A total of 166,131 out-patient attendances (OPD) were evaluated at 21 intervention LLHCFs. Overall use of RDTs resulted in a 38% point reduction in AMD prescriptions. There was a two-fold reduction (RR 0.62, 95% CI 0.55-0.70) in AMD prescription with the greatest reduction in the hypo-endemic setting (RR 0.46 95% CI 0.51-0.53) but no significant change in the urban setting (RR1.01, p-value = 0.820). Over 90% of all eligible OPD patients were offered a test. An average of 30% (range 25%-35%) of the RDT-negative fever patients received AMD prescriptions. When the test result was negative, children under five years of age were two to three times more likely (OR 2.6 p-value <0.001) to receive anti-malarial prescriptions relative to older age group. Of the 63 HWs interviewed 92% believed that a positive RDT result confirmed malaria, while only 49% believed that a negative RDT result excluded malaria infection.</p> <p>Conclusion</p> <p>Use of RDTs resulted in a 2-fold reduction in anti-malarial drug prescription at LLHCFs. The study demonstrated that RDT use is feasible at LLHCFs, and can lead to better targetting of malaria treatment. Nationwide deployment of RDTs in a systematic manner should be prioritised in order to improve fever case management. The process should include plans to educate HWs about the utility of RDTs in order to maximize acceptance and uptake of the diagnostic tools and thereby leading to the benefits of parasitological diagnosis of malaria.</p

A Treatment Outline for Depressive Disorders: The Quality Assurance Project

With College and Government support the Quality Assurance Project is developing a series of explicit and detailed treatment outlines of major psychiatric disorders for use in peer review. Three sources of information are used: a meta-analysis of the treatment outcome literature, the opinions of a sample of practising psychiatrists and the views of a panel of nominated experts. The present outline concerns the treatment of depressive disorders. The three sources of information were in agreement that tricyclic and allied antidepressants were the treatments of choice for endogenous depression and were also to be considered in persistent neurotic depressions. Electroconvulsive therapy was recommended in patients with endogenous depression who were severely ill, troubled by hallucinations and delusions or for whom the antidepressant drugs had not proven effective. The psychotherapies, both dynamic and behavioural, were regarded as the treatments of choice in neurotic depression