This Week's News 5 August 2011

Wajir - Bearing the Brunt of the Drought in Northern Kenya

AMREF

29/07/2011
Wajir Background

For as far as the eye can see, the area surrounding Wajir town is covered in a carpet of loose red soil, dotted with a stubble of hardy thorn trees and leafless bushes. July is the ‘winter’ season in this arid district of northern Kenya, and while the mornings are relatively cool, the temperature rises quickly and by mid-afternoon, it is 36 degrees centigrade and rising.

Wajir County is one of the regions hardest hit by the ongoing drought, with a total of 205,265 people in dire need of food. The area is characterised by long dry spells and short erratic rainy seasons. The rains have failed in the past two seasons, hence the current drought. Beyond Wajir town, most of the county is covered in rocky terrain that is unsuitable for agriculture, and so livestock keeping is the main source of livelihood. This sector, however, is susceptible to many setbacks, including the frequent droughts and diseases. Nutrition status in the district is usually poor, with extremely high cases of malnutrition reported in dry seasons.
Influx of pastoralists and refugees from Somalia, many of them severely malnourished, has exerted severe pressure on local medical facilities. While food scarcity is a major factor in malnutrition, the impact of poor hygiene practices and disease are also contributing to the high malnutrition levels.
Mothers in danger

Steven Mwangi, the nurse in charge of the Maternity Ward at the Wajir District Hospital, a government-run facility, says there is an increase in the number of pregnant women being diagnosed with anaemia as a result of the drought. The combination of living in a harsh environment, and malnutrition, has resulted in an increase in preeclampsia – high blood pressure in pregnancy. Consequently, women are increasingly giving birth prematurely or having babies with low birth weights. This is made worse by the fact that with nothing to eat, the emaciated mothers are unable to breastfeed their babies.

Steven adds that the women who come to deliver in the hospital are just a fraction of those in need of the service; most deliveries happen at home with the help of traditional birth attendants. Habiba Sheikh Mursai lives in El Adow village, 10km from Wajir town, and has been delivering babies for close to 40 years. She is worried about the fact that her clients are very weak, which can cause complications during delivery.
“I am usually able to handle the deliveries on my own, but now I am seeing more and more women who are very frail,” says Habiba. “Since the drought began, I have been attending to more women because families who lost their livestock have moved here from other areas, where they do not get food relief. Here, we get food relief from the government, but it is very little. Because the pregnant women are malnourished, they do not have enough blood, and they do not have the strength to push the babies out. This is not good because it can lead to complications. When I see that I am unable to handle such cases, I send them to the Wajir Hospital. But there are no vehicles from here, so they are taken on donkey carts.”
Pastoralist dropouts

Hawa Abdi has only recently moved to El Adow village, together with her husband, their six children, and her mother-in-law. Her igloo-shaped stick-and-grass dwelling is at the edge of village, together with those of other recent immigrants. “We came from Gambis - out there in the bush. We owned a lot of animals, but they died because of the drought. Out of our 100 goats, only these two survived. Without our goats, and with nothing to eat, we had to come here.”

Hawa’s husband is not home. He has gone to Wajir town to see if he can get some food for his family. The family is not on the food rationing programme, so they have been surviving on handouts from neighbours.
Do they hope to go back to Gambi?

“We came here because we can be able to get a little food. Also, there is water. This is our home now – we will stay here. We cannot go back because we do not have any animals,” Hawa says quietly.

Hawa and her family are what Wajir District Officer 1 Thomas Bett refers to as “pastoralist dropouts”, people who have been forced by the drought to abandon their pastoralist lifestyle and to seek refuge in permanent towns and villages.
Says Bett: “We have had about 10,000 people moving into the outskirts of Wajir town within the last two months, and the numbers are increasing. The town is expanding as they build shelters to live in. They come hoping to find food and water. People in this community share what they have, even when they have very little. One cannot eat alone when the neighbour has nothing.”
According to Bett, the government has been doing its best to alleviate the suffering of the people as a result of the drought. There are 660,000 people in the county. Pastoralist centres have been created where food and water are distributed – but these supplies are few and far between. Since June, the government has distributed 4,000 bags each of maize, rice and beans, as well as cooking oil across the county. Water is trucked to these centres and to villages, but it is a cumbersome and expensive exercise, considering the long distances, rough terrain and high cost of fuel.
Dead means of livelihood

Most of the pastoralists moving to the permanent settlements are women and children. This is because when the drought began, the men and boys moved away with most of the animals in search of water and pasture. Left alone with no source of food, the women are eventually pushed by hunger to leave their homes and travel by foot, in their weakened state, to a place where they might get food and water.

Abdia Isak, her daughter and five grandchildren travelled 50 km on foot from Griftu in the western part the county and arrived in Wajir town a month ago. They set up camp near the Makoror dispensary on the outskirts of the town. Abdia’s son later joined them. Abdia is looking after her grandchildren while their parents go into town to look for casual work.
“We had to come here so that we could find a way to survive. All our animals died because there was no pasture and there was no water. We depended on them for everything. When we needed to buy food, we would sell a goat. We had camels and cows too for milk. Now we depend on neighbours to share their food with us.”
The arid nature of Wajir County makes it unsuitable for agricultural activity. Livestock breeding is the main economic activity, and it is from animals that the people mainly derive their food and livelihood. But evidence of the devastation that the drought has wrought on the lives of the people here is literally littered all over the landscape - carcasses of and skeletons of goats, cows. With no pasture or water, the animals eventually succumb to starvation. Those that manage to reach Wajir town are so emaciated or diseased that they do not attract any buyers, or are sold for a fraction of what they are worth. Before the drought, a cow was valued at 12,000 (US150) shillings. Now, a pastoralist will be lucky to get Sh3, 000 (US$37) for it. A goat that sold for Sh3, 000 is now Sh500 (US$6)….Continued

Full Text: http://www.amref.org/news/wajir--bearing-the-brunt-of-the-drought-in-northern-kenya/

6

What more might the BMJ do in Africa? (20) Promoting health research in Africa

HIFA2015

03/08/2011
Discussion group

posté hier par Joseph Ana de email

For health workers to publish there must be the material in the first place. And this is why the curriculum and faculty for the BMJ West Africa annual Writing Skills workshops extends beyond 'How to Read, Write and Publish' to conducting clinical Audits and writing them up for publication; 'critical appraisal of research papers'; and 'applying research results in practice'. The whole idea is to create awareness of the lack of local research (and results on local problems) and to promote reflective practice, clinical audit and clinical research, all of which are relatively easier and cheaper than original research (experimental research). With the expectation that from that baseline enough interest will be generated to progress to original research.
The issue of lack of funding for research in Nigeria continues to baffle me, including when it came up at the Abuja & Bauchi venues of this year's BMJWA writing workshop. The tertiary institutions and ministries of health (federal & state) are headed by doctors who prepare the budgets, and yet there is no budget line for Continuing Professional Development for doctors. Shocking! It will be nice to know what obtains in other African countries. As commissioner for Health in Cross River State of Nigeria, 2004-2008, I led the setting up of a pilot that led to the creation of a Department of Clinical Governance, Servicom and e-Health. One of the units in the department covers biomedical research and training (with a research ethics committee in operation). Of course, the whole operation is funded under the ministry of health budget. So, I think the politicians who control the purse can be convinced if they are presented with a good case backed by evidence that it works for patients (voters). We must not be deterred from raising the issue at every opportunity, medium and meetings: local, national, regional and international. 'Supporting and assisting the creation of research awareness and building local capacity for doing research', is one of the suggestions to the list in the on-going debate about 'what more can the BMJ do for Africa.'
HIFA2015 profile: Joseph Ana is the Mentor of BMJ West Africa edition. He was Commissioner for Health of Cross River State of Nigeria for four years (July 2004-June2008). Previously he was a GP Principal and trainer in Leighton Buzzard, Bedfordshire, UK. He originally trained as a medical doctor in Nigeria, graduating in 1978 before proceeding to the United Kingdom to specialise in surgery and urology. He is a pioneer Trustee-Director of the NMF (Nigerian Medical Forum) which took the BMJ to West Africa in 1996. He is particularly interested in setting up and sustaining continuing professional development for doctors, nurses and other health workers in West Africa, especially for those in isolated rural hospitals. With the assistance of The BMJ, he established the first, model, BMJWA Health Information Resource Centre in Calabar, Nigeria in 2003 to provide subsidised electronic and paper health information to colleagues. Since taking up post as Commissioner for Health in 2004, he has introduced Clinical Governance, Research and Training to Nigeria and has set up the first Centre for Clinical Governance, Research and Training (CCGRT) in Calabar that functions as the Health Think Tank in Cross River State, thereby eliminating the strictures imposed on health care delivery by the routines of the civil service. jneana AT yahoo.co.uk

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Medical Journals

1

UN High-Level Meeting on Non-Communicable Diseases: addressing four questions

The Lancet, UK

30/07/2011

Volume 378, Issue 9789, Pages 449 – 455
Prof Robert Beaglehole DSc a , Prof Ruth Bonita PhD a, George Alleyne MD b, Richard Horton FMedSci c, Prof Liming Li MD d, Paul Lincoln BSc e, Prof Jean Claude Mbanya MD f, Prof Martin McKee MD g, Prof Rob Moodie MBBS h, Sania Nishtar MD i, Prof Peter Piot MD g, Prof K Srinath Reddy DM j, David Stuckler PhD k, for The Lancet NCD Action Group
Summary

Non-communicable diseases (NCDs), principally heart disease, stroke, cancer, diabetes, and chronic respiratory diseases, are a global crisis and require a global response. Despite the threat to human development, and the availability of affordable, cost-effective, and feasible interventions, most countries, development agencies, and foundations neglect the crisis. The UN High-Level Meeting (UN HLM) on NCDs in September, 2011, is an opportunity to stimulate a coordinated global response to NCDs that is commensurate with their health and economic burdens. To achieve the promise of the UN HLM, several questions must be addressed. In this report, we present the realities of the situation by answering four questions: is there really a global crisis of NCDs; how is NCD a development issue; are affordable and cost-effective interventions available; and do we really need high-level leadership and accountability? Action against NCDs will support other global health and development priorities. A successful outcome of the UN HLM depends on the heads of states and governments attending the meeting, and endorsing and implementing the commitments to action. Long-term success requires inspired and committed national and international leadership.

Introduction

In recognition of the global threat of non-communicable diseases (NCDs)—mainly heart disease, stroke, cancer, diabetes, and chronic respiratory diseases—the UN High-Level Meeting (UN HLM) on NCDs will be held in September, 2011.1 The world's heads of states and governments will attend the meeting, creating a unique opportunity to advance globally the prevention and treatment of NCDs. An urgent and collective response is required because no country alone can address a threat of this magnitude. We know what needs to be done, and have set out five overarching actions—ie, leadership, prevention, treatment, international cooperation, and monitoring and accountability—in a previous report.2 These are needed to enable the implementation of five priority interventions—ie, tobacco control, salt reduction, improved diets and physical activity, reduction of hazardous alcohol intake, and access to essential drugs and technologies.2 However, despite substantial evidence in favour of concerted action, some countries, development agencies, and individuals still express concerns about how to achieve the best response to NCDs.3 To ensure the UN HLM results in consensus for an effective global response to NCDs, four questions need to be addressed—ie, are NCDs a global crisis; in what way is NCD a development issue; are affordable and cost-effective multisectoral and health-system interventions available; and why are high-level leadership and accountability necessary?

In this report, we address these questions by providing evidence for the realities of the NCD situation, and summarise key messages for heads of state and governments. Specifically, we show that the burden of global NCDs is huge, and will undermine current development efforts if it remains unaddressed; a strong business case exists for investment in NCDs; cost-effective and feasible multisectoral and health-system interventions are available for all countries; and progress requires sustained leadership and accountability.
NCDs and the global crisis

NCDs pose a global threat and require a global response. The burden of death and disability attributable to NCDs is rising everywhere because of the changing patterns in the way we live and work; millions of people are dying needlessly every year.4 NCDs are not just a domestic challenge, but also cause and entrench poverty, and are a threat to human, social, and economic development. The 36·1 million deaths per year as a result of NCDs represent almost two of three deaths per year worldwide.5 22·4 million of these deaths arise in the poorest countries, and 13·7 million in high-income and upper-middle-income countries (figure 1)

Key messages

•NCDs threaten economic and human development; action against NCDs will support overall development goals, including the Millennium Development Goals

•The global crisis in non-communicable diseases (NCDs) requires a global multisectoral response
•Strong national and international leadership is essential; tackling NCDs should be part of both national and international health and development agendas
•Population-wide multisectoral preventive interventions are cost saving and will have a rapid effect
•Improving primary health care for prevention and treatment in people at high risk of NCDs is cost effective
•Efficient use of existing resources and new innovative financing methods are needed, not a new global fund
•The success of the UN High-Level Meeting on NCDs requires the participation of the heads of states and governments, and commitment to sustained action and accountability
The data do not support the fallacious argument that NCDs are only problems for elderly men in wealthy countries or wealthy men in poor countries. There are as many deaths in women as there are in men, and poor people are disproportionately affected. NCD death rates are already much higher in low-income and lower-middle-income than in wealthy countries (figure 2). Almost two-thirds (63%) of premature deaths in adults (aged 15—69 years), and three of four of all adult deaths are attributable to NCDs. In all countries, NCDs are the major health issue for men and women, and are a serious issue for all health-care systems. ....Continued

Full-text: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60879-9/fulltext?_eventId=login

2

Individualized Cost-Effectiveness Analysis

PLoS Medicine

12/07/2011

John P. A. Ioannidis1*, Alan M. Garber2,3
1 Stanford Prevention Research Center, Department of Medicine and Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California, United States of America, 2 Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California, United States of America, 3 Veterans Affairs Palo Alto Health Care System, Stanford, California, United States of America
Citation: Ioannidis JPA, Garber AM (2011) Individualized Cost-Effectiveness Analysis. PLoS Med 8(7): e1001058. doi:10.1371/journal.pmed.1001058
Copyright: © 2011 Ioannidis, Garber. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: No funding was received for this work.

Competing interests: JI is a member of the PLoS Medicine Editorial Board. The authors have declared that no other competing interests exist.

Abbreviations: ICER, incremental cost-effectiveness ratio; QALD, quality-adjusted life day; QALY, quality-adjusted life year

* E-mail: [e-mail]

Provenance: Not commissioned; externally peer reviewed
Summary Points

Cost-effectiveness analyses typically express their principal results as incremental cost-effectiveness ratios (ICERs).

ICERs are useful in making decisions for allocation of resources at a population level, but typical ICER measures have shortcomings when used for individual decisions.

For the same ICER, the cost-effectiveness may vary among individuals because not everyone assigns the same priorities to specific outcomes, shares the same attitudes toward risk, or faces the same distribution of expected outcomes.

ICER information can be enhanced by providing additional metrics that individualize cost-effectiveness analyses.
These metrics include the per person net benefit and cost, subgroup ICER estimates for observed measured sources of heterogeneity, and distributions of outcomes and costs for unknown or unmeasured sources of heterogeneity.
The results of a typical cost-effectiveness (cost–utility) analysis are expressed by the incremental cost-effectiveness ratio (ICER) [1]: the money required to gain a quality-adjusted life year (QALY) (i.e., one year with best possible quality of life) at a population level. The ICER concept is valuable for choosing among diverse interventions competing for limited resources. It was developed primarily for societal or group-level decisions, such as allocations of a fixed governmental health budget, and consequently is particularly helpful for health authorities and other decision-makers who wish to prioritize resource allocation in health care to numerous interventions on diverse diseases across whole systems. The major contribution of ICER to inform population-level decisions is even more obvious today, as health care costs are escalating and rational choices need to be made on how to contain cost without compromising health outcomes at the societal level. However, conventional ICERs are population-level tools, and fail to take into account important inter-individual differences that might affect the value of a particular intervention. The choice that maximizes the population's health or has the best ICER overall is not always the same as the best choice for a specific individual. Moreover, the best choices may differ for different individuals. There is thus interest in how to modify the ICER concept for applications in individual decision-making [2],[3]. In this essay, we aim to contribute to the discussion on how to use ICER and related metrics in a way that would be more useful for decision-making at the individual level, whether used by clinicians or individual patients.
The Concept of Individualized Cost-Effectiveness and Individual Choices Top

By convention, the numerator of the ICER is the difference in cost of care between compared interventions. The denominator is the corresponding difference in health outcomes (usually measured in QALYs). The denominator combines disparate kinds of information: diverse health benefits and harms are summed into a net health outcome measure.

As typically measured, the ICER appraises the average experience with an intervention. However, several investigators have pointed out that working with averages is not good enough. According to Kravitz et al. [4], “averages do not apply to everyone.” As is now well-recognized, averages are problematic for interpreting clinical evidence, e.g., the results of randomized trials, where treatment effects (benefits, but also harms) are often heterogeneous, i.e., different for different types of patients [5]–[7]. The same challenges arise when one considers cost-effectiveness and decision-making. After all, randomized trials and other clinical studies typically feed their data into decision and cost-effectiveness models. Moreover, the granularity of the cost and outcomes per patient may be important to convey, i.e., specifying separately the different outcomes, so that clinicians and patients may be better informed and able to make better choices….Continued

Full Text: http://clinicaltrials.ploshubs.org/article/info:doi/10.1371/journal.pmed.1001058

3

The effect of mobile phone text-message reminders on Kenyan health workers' adherence to malaria treatment guidelines: a cluster randomised trial

The Lancet, UK

04/08/2011

Dr Dejan Zurovac PhD a b c , Raymond K Sudoi BSc a, Willis S Akhwale PhD d, Moses Ndiritu MD a, Davidson H Hamer MD c e, Alexander K Rowe MD f, Prof Robert W Snow FMedSci a b
Summary

Background

Health workers' malaria case-management practices often differ from national guidelines. We assessed whether text-message reminders sent to health workers' mobile phones could improve and maintain their adherence to treatment guidelines for outpatient paediatric malaria in Kenya.
Methods

From March 6, 2009, to May 31, 2010, we did a cluster-randomised controlled trial at 107 rural health facilities in 11 districts in coastal and western Kenya. With a computer-generated sequence, health facilities were randomly allocated to either the intervention group, in which all health workers received text messages on their personal mobile phones on malaria case-management for 6 months, or the control group, in which health workers did not receive any text messages. Health workers were not masked to the intervention, although patients were unaware of whether they were in an intervention or control facility. The primary outcome was correct management with artemether-lumefantrine, defined as a dichotomous composite indicator of treatment, dispensing, and counselling tasks concordant with Kenyan national guidelines. The primary analysis was by intention to treat. The trial is registered with Current Controlled Trials, ISRCTN72328636.

Findings

119 health workers received the intervention. Case-management practices were assessed for 2269 children who needed treatment (1157 in the intervention group and 1112 in the control group). Intention-to-treat analysis showed that correct artemether-lumefantrine management improved by 23·7 percentage-points (95% CI 7·6—40·0; p=0·004) immediately after intervention and by 24·5 percentage-points (8·1—41·0; p=0·003) 6 months later.

Interpretation

In resource-limited settings, malaria control programmes should consider use of text messaging to improve health workers' case-management practices.

Funding

The Wellcome Trust.

Introduction

With more than 5 billion mobile phone users worldwide, text-messaging technology has changed the face of communication globally, and is increasingly used to promote health and to prevent disease.1, 2 The application of text messaging for behavioural change in health is at an early stage of research. Randomised controlled trials of such use of text messaging are scarce, with only two trials from low-resource settings.3, 4 Most randomised controlled trials from high-income countries have focused on reminders to improve patients' adherence to treatment, and all studies assessed only short-term effects of the intervention.5—7 We know of no other study that has assessed the use of text messaging to target the behaviour of health workers.5—7

In Africa, adherence by health workers to malaria case-management guidelines for artemisinin-based combination treatment is vital to maximise patients' adherence to treatment,8, 9 and, therefore, treatment success.10 Despite simple guidelines for the management of febrile children, non-adherent prescription, dosing, and dispensing of drugs, and counselling practices that do not conform to these established guidelines have been widely reported at outpatient facilities across the continent.11—14 Complex interventions such as high quality in-service training, supervision, audit with feedback, and quality improvement schemes have been suggested as interventions to improve the use of drugs and adherence to guidelines in low-resource settings.15, 16 However, little information exists about the cost-effectiveness of such interventions and about the possible existence of simple, inexpensive, and effective interventions that could be easily replicated in similar settings.16
Notwithstanding poor health indicators, restricted resources, poor infrastructure, and weak health systems, many African countries have overcome communication problems with the widespread use of mobile phone technology.2, 17 In this study, we report a randomised controlled trial in Kenya designed to test whether text-message reminders sent to health workers' mobile phones could improve and maintain health-workers' adherence to national guidelines for the management of outpatient paediatric malaria with the recommended artemisinin-based combination treatment in Kenya—artemether-lumefantrine.
Methods

Study population

This cluster randomised controlled trial was done at all 107 rural government health facilities (dispensaries and health centres) in 11 districts in two malaria endemic areas in Kenya: Greater Kwale, located along the Indian Ocean coast with a population of 650 000 people; and Greater Kisii and Gucha, located in the western highlands with a population of 1 030 000 people. In both areas, artemether-lumefantrine was deployed to health facilities in August, 2006. Between September, 2006, and July, 2009, the main artemether-lumefantrine implementation activities in study districts consisted of three rounds of malaria case-management training sessions for health workers and dissemination of national guideline documents and drug management wall charts.
Written informed consent was obtained from all interviewed carers and health workers. The study protocol was approved by the University of Oxford (OXTREC No 3808) and Kenya Medical Research Institute (SSC No 1329). The trial is registered with Current Controlled Trials, ISRCTN72328636.

Randomisation and masking

All health facilities (study clusters), stratified by study area, were randomly allocated to either the intervention or control group, with a computer-generated sequence (generated by the research team). Researchers and health workers were not masked to intervention although patients and carers were unaware whether they were in an intervention or control group.
Procedures

The intervention was a one-way communication of text-message reminders about paediatric malaria case-management sent to health workers' personal mobile phones. All health workers doing outpatient consultations in the intervention group received text messages about malaria case-management for 6 months. The intervention did not include the provision of a mobile phone. The key messages addressed recommendations from the Kenyan national malaria guidelines18 and training manuals.19 The messages were in English, the language of pre-service and in-service training of Kenyan health workers.19 We created ten different text-messages (panel 1) to communicate the content and order of the key aspects of the outpatient clinical process with respect to paediatric malaria case management. For 5 working days (Monday to Friday), two text messages (one at 9 am and one at 2 pm) were sent daily (excluding public holidays) to every health worker's mobile phone. The same process was repeated every week for 6 months. This long intervention period was selected to ensure high exposure to the intervention to show proof of concept. Each case-management message was up to 120 characters long. To increase the probability that health workers would read the messages, each message was complemented with a quote that was up to 40 characters long and unrelated to malaria case-management but designed to be motivating, entertaining, or merely attention-getting.20 The quotes were unique to each message sent to health workers. The maximum number of characters in each message was 160, which is the maximum amount of text that can be sent in a text message to most mobile phones in Kenya. Before the trial, the text messages were pretested in neighbouring study districts during two rounds of individual interviews with 20 health workers who had similar roles to health workers in the study areas. This pretesting showed that most messages were understood—some messages needed further simplification and refinement before being finalised and eventually used......Continued

Full-text and tables: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60783-6/fulltext?_eventId=login